Provider Demographics
NPI:1336524040
Name:COTTRELL, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:COTTRELL
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 1:1201 S MILLER ST
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801
Mailing Address - Country:US
Mailing Address - Phone:509-662-1511
Mailing Address - Fax:509-665-6261
Practice Address - Street 1:1201 S MILLER ST
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-3201
Practice Address - Country:US
Practice Address - Phone:509-662-1511
Practice Address - Fax:509-665-6261
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA86026446133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01663048OtherRR PTAN WVH
WA1336524040Medicaid
WAG8953084, G8953085Medicare PIN