Provider Demographics
NPI:1508264185
Name:BAYNE, JENNIFER AL (LW60694899)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:AL
Last Name:BAYNE
Suffix:
Gender:F
Credentials:LW60694899
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:MS: 315-C4-CHF
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405
Mailing Address - Country:US
Mailing Address - Phone:253-403-1408
Mailing Address - Fax:253-403-4591
Practice Address - Street 1:315 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:MS: 315-C4-CHF
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:253-403-1408
Practice Address - Fax:253-403-4591
Is Sole Proprietor?:No
Enumeration Date:2014-12-12
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC60364820104100000X
WALW606948991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker