MEDICARE: MRS. JESSIE JIYEON DZIDUCH FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	RN61340403	WA
2	363L00000X	Nurse Practitioner	AP61340468	WA

General Provider Information

NPI Number	:	1265900591
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSIE JIYEON DZIDUCH FNP-C

Provider Business Mailing Address
First Line	:	7600 EVERGREEN WAY
Second Line	:
City	:	EVERETT
State	:	WA
Zip	:	98203-6421
Country	:	US
Telephone Number	:	206-860-5414
Fax Number	:

Provider Business Practice Location Address
First Line	:	4011 172ND ST NE
Second Line	:
City	:	ARLINGTON
State	:	WA
Zip	:	98223-8482
Country	:	US
Telephone Number	:	142-525-9096
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2018
Last Update Date	:	05/04/2026

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