Provider Demographics
NPI:1164620498
Name:GARDNER, JEAN
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 S I ST
Mailing Address - Street 2:#206
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5016
Mailing Address - Country:US
Mailing Address - Phone:253-426-6753
Mailing Address - Fax:253-426-6014
Practice Address - Street 1:1624 S I ST
Practice Address - Street 2:#206
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5016
Practice Address - Country:US
Practice Address - Phone:253-426-6753
Practice Address - Fax:253-426-6014
Is Sole Proprietor?:No
Enumeration Date:2007-07-09
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000386133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered