Provider Demographics
NPI:1750466553
Name:FANN, JESSE R
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:R
Last Name:FANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF WASHINGTON MEDICAL CTR
Practice Address - Street 2:1959 NE PACIFIC ST
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-6560
Practice Address - Country:US
Practice Address - Phone:206-598-6195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000291202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0175609OtherL&I
WA1750466553Medicaid
8881OtherINTERNAL ID-MOTOR VEHICLE ID
WA1750466553Medicaid
WA000108022Medicare PIN