Healthcare Provider Details

I. General information

NPI: 1699432856
Provider Name (Legal Business Name): MRS. ELIZABETH JANE WHITAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2021
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
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: 443-784-1553
  • Fax:
Mailing address:
  • Phone: 443-783-1553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: