Provider Demographics
NPI:1437160140
Name:JENNER, CARRIE L (MD)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:JENNER
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 1:7210 40TH ST W
Mailing Address - Street 2:STE 100
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4237
Mailing Address - Country:US
Mailing Address - Phone:253-564-0170
Mailing Address - Fax:253-207-4240
Practice Address - Street 1:7210 40TH ST W
Practice Address - Street 2:STE 100
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4237
Practice Address - Country:US
Practice Address - Phone:253-564-0170
Practice Address - Fax:253-207-4240
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034173208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA126537OtherL & I
WA8208399Medicaid
WA370013713OtherRAILROAD
WA8935092OtherCRIME VICTIMS
WAGAB08494Medicare PIN
WA126537OtherL & I
WA8208399Medicaid