Basic Information
| Provider Information | |||||||||
| NPI: | 1417993148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BATES | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 709 W ORCHARD DR | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982251766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603188800 | ||||||||
| FaxNumber: | 3603181085 | ||||||||
| Practice Location | |||||||||
| Address1: | 5580 NORDIC WAY | ||||||||
| Address2: | |||||||||
| City: | FERNDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982489138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603841511 | ||||||||
| FaxNumber: | 3603845758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 07/02/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00037647 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4582BA | 01 | WA | REGENCE BLUESHIELD | OTHER | 423898071 | 01 | WA | GROUP HEALTH COOPERATIVE | OTHER | 8252249 | 05 | WA | MEDICAID | 0188849 | 01 | WA | LABOR & INDUSTRIES (REG) | OTHER | P00181773 | 01 | WA | RAILROAD MEDICARE | OTHER | 8938884 | 01 | WA | LABOR & INDUSTRIES (CV) | OTHER |