Provider Demographics
NPI:1588607535
Name:WIGGINS, JODI LEE
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:LEE
Last Name:WIGGINS
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 1:3121 WAVE DR
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-1355
Mailing Address - Country:US
Mailing Address - Phone:425-773-7555
Mailing Address - Fax:
Practice Address - Street 1:11020 19TH AVE SE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-5155
Practice Address - Country:US
Practice Address - Phone:425-337-7197
Practice Address - Fax:425-337-9287
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA00040298183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician