Provider Demographics
NPI:1922052109
Name:JENNY, CAROLE (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROLE
Middle Name:
Last Name:JENNY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 DECATUR IS
Mailing Address - Street 2:DECATUR ISLAND
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-9402
Mailing Address - Country:US
Mailing Address - Phone:360-375-6277
Mailing Address - Fax:
Practice Address - Street 1:10 DECATUR IS
Practice Address - Street 2:DECATUR ISLAND
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-9402
Practice Address - Country:US
Practice Address - Phone:360-375-6277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000154172080C0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080C0008XAllopathic & Osteopathic PhysiciansPediatricsChild Abuse Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RICJ30400Medicaid
RI007010291Medicare PIN
RIE30789Medicare UPIN