Provider Demographics
NPI:1194980193
Name:ALLEN-RICH, JENNIE MICHELLE (MD)
Entity type:Individual
Prefix:MS
First Name:JENNIE
Middle Name:MICHELLE
Last Name:ALLEN-RICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 S J ST STE 102
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4100
Mailing Address - Country:US
Mailing Address - Phone:253-396-4868
Mailing Address - Fax:253-396-4870
Practice Address - Street 1:603 S J ST STE 102
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4100
Practice Address - Country:US
Practice Address - Phone:253-396-4868
Practice Address - Fax:253-396-4870
Is Sole Proprietor?:No
Enumeration Date:2008-07-20
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML60019662208000000X
WAMD602172352080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2018803Medicaid