Provider Demographics
NPI:1356341697
Name:CARL, JENNIFER W
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:W
Last Name:CARL
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 1:1192 57TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-1225
Mailing Address - Country:US
Mailing Address - Phone:360-379-3590
Mailing Address - Fax:360-385-5452
Practice Address - Street 1:1233 W SIMS WAY
Practice Address - Street 2:POB 165
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-3057
Practice Address - Country:US
Practice Address - Phone:360-379-5743
Practice Address - Fax:360-385-5452
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00021898208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA250014089Medicare PIN
WAAB27762Medicare PIN
WAGAB00919Medicare PIN
WAA06271Medicare UPIN