Provider Demographics
NPI:1073583878
Name:SODEN, JENNIFER L (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:SODEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 NE 87TH AVE
Mailing Address - Street 2:STE 120
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1989
Mailing Address - Country:US
Mailing Address - Phone:360-892-1635
Mailing Address - Fax:360-892-3146
Practice Address - Street 1:505 NE 87TH AVE
Practice Address - Street 2:STE 120
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1989
Practice Address - Country:US
Practice Address - Phone:360-892-1635
Practice Address - Fax:360-892-3146
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000412172080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8316689Medicaid