Provider Demographics
NPI:1780080515
Name:VAN BLARICOM, JACIE L (DI)
Entity type:Individual
Prefix:
First Name:JACIE
Middle Name:L
Last Name:VAN BLARICOM
Suffix:
Gender:F
Credentials:DI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 FORTUYN RD
Mailing Address - Street 2:
Mailing Address - City:GRAND COULEE
Mailing Address - State:WA
Mailing Address - Zip Code:99133-8718
Mailing Address - Country:US
Mailing Address - Phone:509-633-1753
Mailing Address - Fax:509-633-1933
Practice Address - Street 1:411 FORTUYN RD
Practice Address - Street 2:
Practice Address - City:GRAND COULEE
Practice Address - State:WA
Practice Address - Zip Code:99133-8718
Practice Address - Country:US
Practice Address - Phone:509-633-1753
Practice Address - Fax:509-633-1933
Is Sole Proprietor?:No
Enumeration Date:2014-11-05
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60513122133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2040919Medicaid