Provider Demographics
NPI:1639822786
Name:ODONGI, JESICA
Entity Type:Individual
Prefix:
First Name:JESICA
Middle Name:
Last Name:ODONGI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32278 48TH CT S
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-2632
Mailing Address - Country:US
Mailing Address - Phone:302-544-2834
Mailing Address - Fax:844-529-8515
Practice Address - Street 1:3629 S D ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-6813
Practice Address - Country:US
Practice Address - Phone:253-649-1406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-29
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61245108363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty