Provider Demographics
NPI:1023309473
Name:ERICKSON, JENNIFER MARIE (DO)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MARIE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:DO
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:98195-6560
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:2505 2ND AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98121-1452
Practice Address - Country:US
Practice Address - Phone:206-443-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP 606216452084P0015X, 2084P0015X
NMA-1799-142084P0800X
NY279161-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1023309473Medicaid
WA1023309473Medicaid