Basic Information
| Provider Information | |||||||||
| NPI: | 1053403444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENICH | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | JUDITH | ||||||||
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| Credential: | MS, RD, CD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7332 11TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981174141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062971787 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4800 SAND POINT WAY NE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981053901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069872000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DI00001227 | WA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 8272098 | 05 | WA | MEDICAID |