Provider Demographics
NPI:1629492673
Name:BANDA, JENNIFER A (CNM)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:BANDA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:REYNICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1608 S J ST
Mailing Address - Street 2:FLOOR 1
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4930
Mailing Address - Country:US
Mailing Address - Phone:253-274-7501
Mailing Address - Fax:253-274-7991
Practice Address - Street 1:1608 S J ST
Practice Address - Street 2:FLOOR 1
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4930
Practice Address - Country:US
Practice Address - Phone:253-274-7501
Practice Address - Fax:253-274-7991
Is Sole Proprietor?:No
Enumeration Date:2014-02-11
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001609367A00000X, 176B00000X
WAAP60427514367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA347010OtherSTATE L&I
WA347010OtherSTATE L&I