Provider Demographics
NPI:1437370111
Name:RIDDICK, JACQUELINE VASEN (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:VASEN
Last Name:RIDDICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:VASEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1511 6TH AVE STE 360
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1759
Mailing Address - Country:US
Mailing Address - Phone:206-470-1860
Mailing Address - Fax:206-834-9591
Practice Address - Street 1:909 UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2772
Practice Address - Country:US
Practice Address - Phone:206-470-1860
Practice Address - Fax:206-834-9591
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 60041895207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8563348Medicaid
WA8563348Medicaid