Provider Demographics
NPI:1700239217
Name:COLVIN, JEANIE (ADDP COORDINATOR)
Entity Type:Individual
Prefix:
First Name:JEANIE
Middle Name:
Last Name:COLVIN
Suffix:
Gender:F
Credentials:ADDP COORDINATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11572 17TH AND C ST.
Mailing Address - Street 2:
Mailing Address - City:JBLM
Mailing Address - State:WA
Mailing Address - Zip Code:98433
Mailing Address - Country:US
Mailing Address - Phone:253-966-7680
Mailing Address - Fax:253-967-7612
Practice Address - Street 1:11572 17TH AND C ST.
Practice Address - Street 2:
Practice Address - City:JBLM
Practice Address - State:WA
Practice Address - Zip Code:98433
Practice Address - Country:US
Practice Address - Phone:253-966-7680
Practice Address - Fax:253-967-7216
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant