Provider Demographics
NPI:1669935979
Name:PANZA, JESSICA LARAINE (ND)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LARAINE
Last Name:PANZA
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LARAINE
Other - Last Name:WEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:504 E 8TH ST. STE A.
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-3319
Mailing Address - Country:US
Mailing Address - Phone:360-452-5000
Mailing Address - Fax:360-452-0228
Practice Address - Street 1:504 E 8TH ST. STE A.
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3319
Practice Address - Country:US
Practice Address - Phone:360-452-5000
Practice Address - Fax:360-452-0228
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT60943992175F00000X
175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2148760Medicaid