Healthcare Provider Details

I. General information

NPI: 1174819767
Provider Name (Legal Business Name): JEANNIE BAY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-5422
  • Fax:
Mailing address:
  • Phone: 253-968-5422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number0102203223
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: