Basic Information
| Provider Information | |||||||||
| NPI: | 1851069660 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAC | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | VANANH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1802 YAKIMA AVE STE 302 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536271244 | ||||||||
| FaxNumber: | 2536276576 | ||||||||
| Practice Location | |||||||||
| Address1: | 1802 YAKIMA AVE STE 302 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984055305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536271244 | ||||||||
| FaxNumber: | 2536276576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2021 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP61218004 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2202600 | 05 | WA | MEDICAID |