Provider Demographics
NPI:1417165382
Name:LEACH, JENNIFER W (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:W
Last Name:LEACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1439
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 W POPLAR ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2858
Practice Address - Country:US
Practice Address - Phone:509-522-5824
Practice Address - Fax:509-522-5738
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 60212127207RN0300X
ORMD28595207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1417165382Medicaid
OR500635060Medicaid
WAG8904360Medicare PIN