1962521435 NPI number — JENNIFER CASERTA MD

Table of content: JENNIFER CASERTA MD (NPI 1962521435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962521435 NPI number — JENNIFER CASERTA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASERTA
Provider First Name:
JENNIFER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962521435
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1911 COOKS HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTRALIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98531-9073
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-736-6778
Provider Business Mailing Address Fax Number:
360-736-6552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1911 COOKS HILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTRALIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98531-9073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-736-6778
Provider Business Practice Location Address Fax Number:
360-736-6552
Provider Enumeration Date:
03/28/2007

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: 208000000X , with the licence number:  MD00043677 , 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)

  • Identifier: 2914CA . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 9116CA . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 230532008 . This is a "GROUP HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7122617 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7057375 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7131709 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7131717 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8398356 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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