Provider Demographics
NPI:1194045682
Name:ERICKSON, JENNIFER MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26458 MAPLE VALLEY BLACK DIAMOND RD SE
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-8350
Mailing Address - Country:US
Mailing Address - Phone:425-690-3460
Mailing Address - Fax:
Practice Address - Street 1:3021 GRIFFIN AVE
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2369
Practice Address - Country:US
Practice Address - Phone:360-825-6511
Practice Address - Fax:360-825-6536
Is Sole Proprietor?:No
Enumeration Date:2010-06-07
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60157486363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0268930OtherSTATE L&I
WA0268930OtherSTATE L&I