Provider Demographics
NPI:1841661303
Name:TARDIF, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:TARDIF
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 1:12115 STATE AVE
Mailing Address - Street 2:F321
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98271-8585
Mailing Address - Country:US
Mailing Address - Phone:425-366-1790
Mailing Address - Fax:
Practice Address - Street 1:12115 STATE AVE
Practice Address - Street 2:F321
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98271-8585
Practice Address - Country:US
Practice Address - Phone:425-366-1790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60580266101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)