Provider Demographics
NPI:1336379346
Name:PHAM, JEANETTE
Entity Type:Individual
Prefix:DR
First Name:JEANETTE
Middle Name:
Last Name:PHAM
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 1:10219 196TH ST CT E
Mailing Address - Street 2:SUITE A, MAIL BOX # 2
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10219 196TH ST CT E
Practice Address - Street 2:SUITE A, MAIL BOX # 2
Practice Address - City:GRAHAM
Practice Address - State:WA
Practice Address - Zip Code:98338
Practice Address - Country:US
Practice Address - Phone:253-271-7313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA4009152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist