Provider Demographics
NPI:1629666375
Name:VAN DIEST, JODIE NICOLE (PHARMD, BCCCP)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:NICOLE
Last Name:VAN DIEST
Suffix:
Gender:F
Credentials:PHARMD, BCCCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1426 136TH ST SE
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-5303
Mailing Address - Country:US
Mailing Address - Phone:614-483-8831
Mailing Address - Fax:
Practice Address - Street 1:1700 13TH ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1689
Practice Address - Country:US
Practice Address - Phone:425-261-3532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60438818183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist