=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972769412
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNETTE MARIE ANDERSON PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2008
-----------------------------------------------------
Last Update Date | 07/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9040A JACKSON AVE JOINT BASE LEWIS-MCCHORD
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98431-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-560-2683
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | WH3S9A 549 HC / BAACH UNIT 15245
-----------------------------------------------------
City | APO
-----------------------------------------------------
State | AP
-----------------------------------------------------
Zip | 96271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 19829
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------