Provider Demographics
NPI:1407889173
Name:JOSEPH, JACKLINE S (MD)
Entity Type:Individual
Prefix:
First Name:JACKLINE
Middle Name:S
Last Name:JOSEPH
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 1:2103 152ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-5520
Mailing Address - Country:US
Mailing Address - Phone:425-746-2400
Mailing Address - Fax:425-746-2659
Practice Address - Street 1:2103 152ND AVE NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-5520
Practice Address - Country:US
Practice Address - Phone:425-746-2400
Practice Address - Fax:425-746-2659
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD34703207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8206682Medicaid
WAAB34700Medicare ID - Type Unspecified
G44853Medicare UPIN