Provider Demographics
NPI:1881025245
Name:PUGH, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PUGH
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 1:10513 SILVERDALE WAY NW
Mailing Address - Street 2:102
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-9499
Mailing Address - Country:US
Mailing Address - Phone:360-698-4411
Mailing Address - Fax:
Practice Address - Street 1:10513 SILVERDALE WAY NW
Practice Address - Street 2:102
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9499
Practice Address - Country:US
Practice Address - Phone:360-698-4411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024701174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist