Provider Demographics
NPI:1306181755
Name:TAVIS, JENNY-REBECCA FAITH (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JENNY-REBECCA
Middle Name:FAITH
Last Name:TAVIS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5133
Mailing Address - Country:US
Mailing Address - Phone:360-493-5369
Mailing Address - Fax:360-493-7154
Practice Address - Street 1:413 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5133
Practice Address - Country:US
Practice Address - Phone:360-493-5369
Practice Address - Fax:360-493-7154
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60213057183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist