Provider Demographics
NPI:1386830610
Name:FUDGE, JESSIE ROBERTS (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:ROBERTS
Last Name:FUDGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:MARIE
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2930 MAPLE STREET
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201
Mailing Address - Country:US
Mailing Address - Phone:425-502-3600
Mailing Address - Fax:
Practice Address - Street 1:2930 MAPLE ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3832
Practice Address - Country:US
Practice Address - Phone:425-502-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 60141711207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA353780Medicare UPIN