Provider Demographics
NPI:1114312360
Name:PANKS, JESSICA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:PANKS
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:PO BOX 5371
Mailing Address - Street 2:RC-504
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5005
Mailing Address - Country:US
Mailing Address - Phone:206-987-8438
Mailing Address - Fax:
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3901
Practice Address - Country:US
Practice Address - Phone:206-987-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-04
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0060594208000000X
2080C0008X
WAMD61158278208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080C0008XAllopathic & Osteopathic PhysiciansPediatricsChild Abuse Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1114312360Medicaid