Provider Demographics
NPI:1336537612
Name:O'DONNELL, JENNIFER STROUP (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:STROUP
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:ELIZABETH
Other - Last Name:STROUP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1730 MINOR AVE STE 400
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2402
Practice Address - Country:US
Practice Address - Phone:206-320-2961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60509817103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2043212Medicaid
WA2043212Medicaid