Provider Demographics
NPI:1679637003
Name:NEGRETE, JODI C (LMP)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:C
Last Name:NEGRETE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3906 COOPER CREST DR NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-4071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1025 BLACK LAKE BLVD SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-1120
Practice Address - Country:US
Practice Address - Phone:360-402-6284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020160174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00020160OtherLMP