Provider Demographics
NPI:1508056482
Name:MCEVOY, JENNIFER RENAE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:RENAE
Last Name:MCEVOY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:R
Other - Last Name:HUDDLESTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:19020 33RD AVE W STE 210
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4748
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1501
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-121872085R0202X
WI511332085R0202X
AK1015902085R0202X
WAMD602875212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA310105OtherL & I PROVIDER NUMBER
ID1508056482Medicaid
WA309291OtherL & I PROVIDER NUMBER
WA310103OtherL & I PROVIDER NUMBER
AK1678485Medicaid
WA2021772Medicaid
WAG8910337Medicare PIN
WA310105OtherL & I PROVIDER NUMBER
ID1508056482Medicaid
WAP0109649Medicare PIN
WAG8910335Medicare PIN
WAG8910334Medicare PIN