Provider Demographics
NPI:1508961251
Name:WEAVER-FARNAM, JENNIFER (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:WEAVER-FARNAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:WEAVER
Other - Last Name:FARNAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:401 SW 153RD ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-2247
Mailing Address - Country:US
Mailing Address - Phone:206-244-1780
Mailing Address - Fax:206-433-4060
Practice Address - Street 1:401 SW 153RD ST
Practice Address - Street 2:SUITE A
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-2247
Practice Address - Country:US
Practice Address - Phone:206-244-1780
Practice Address - Fax:206-433-4060
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1753 TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2023422Medicaid
WAT60953Medicare UPIN
WA2023422Medicaid