Provider Demographics
NPI:1184259764
Name:JERNIGAN, DARREL W (CG 61020545)
Entity type:Individual
Prefix:
First Name:DARREL
Middle Name:W
Last Name:JERNIGAN
Suffix:
Gender:M
Credentials:CG 61020545
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 PINE ST STE 300
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1959
Mailing Address - Country:US
Mailing Address - Phone:206-323-1768
Mailing Address - Fax:206-323-2184
Practice Address - Street 1:1216 PINE ST STE 300
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1959
Practice Address - Country:US
Practice Address - Phone:206-323-1768
Practice Address - Fax:206-323-2184
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61020545175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA23-7258439OtherNA