Provider Demographics
NPI:1558451443
Name:JAFFE, KENNETH M
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:JAFFE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 SAND POINT WAY NE
Mailing Address - Street 2:#100
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-3900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3901
Practice Address - Country:US
Practice Address - Phone:206-987-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000149582081P0010X
WAMD00015224208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
816OtherINTERNAL ID-MOTOR VEHICLE ID
WA8371106Medicaid
A04799Medicare UPIN
WA8371106Medicaid
816OtherINTERNAL ID-MOTOR VEHICLE ID