Basic Information
| Provider Information | |||||||||
| NPI: | 1952922395 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONGSAMOUTH | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25608 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841250608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063204476 | ||||||||
| FaxNumber: | 2065687043 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 BROADWAY STE 500 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981224396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062155921 | ||||||||
| FaxNumber: | 2062155922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2020 | ||||||||
| LastUpdateDate: | 01/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN61087160 | WA | N | Nursing Service Providers | Registered Nurse | 363L00000X | AP61088873 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1952922395 | 05 | WA | MEDICAID |