Provider Demographics
NPI:1659460905
Name:STEVENS, JENNIFER LYNN (RD, CD, CNSD)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYNN
Last Name:STEVENS
Suffix:
Gender:F
Credentials:RD, CD, CNSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17200 116TH AVE SE
Mailing Address - Street 2:BOX 58215
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-9997
Mailing Address - Country:US
Mailing Address - Phone:206-987-4339
Mailing Address - Fax:206-987-5087
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:M/S W3726
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3901
Practice Address - Country:US
Practice Address - Phone:206-987-4339
Practice Address - Fax:206-987-5087
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000869133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8261752Medicaid