Provider Demographics
NPI:1356679948
Name:TKACH, JENNIFER MICHELE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELE
Last Name:TKACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:DAVIDOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:311 S L ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-3720
Mailing Address - Country:US
Mailing Address - Phone:253-403-1420
Mailing Address - Fax:
Practice Address - Street 1:311 S L ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3720
Practice Address - Country:US
Practice Address - Phone:253-403-1420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-19
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60311888208000000X
UT8684436-1205208000000X
AZR71570208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics