1114130275 NPI number — MS. JENNIFER G. DRAGOO LMP

Table of content: MS. JENNIFER G. DRAGOO LMP (NPI 1114130275)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114130275 NPI number — MS. JENNIFER G. DRAGOO LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DRAGOO
Provider First Name:
JENNIFER
Provider Middle Name:
G.
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TURETZKY
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
G.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114130275
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1804
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMONDS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-697-0178
Provider Business Mailing Address Fax Number:
206-542-6725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9631 FIRDALE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMONDS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-697-0178
Provider Business Practice Location Address Fax Number:
206-542-6725
Provider Enumeration Date:
05/07/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MA00015140W , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X , with the licence number: MA00015140 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)