Provider Demographics
NPI:1962098772
Name:VERNAZA, JESSICA YOLANDA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:YOLANDA
Last Name:VERNAZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 S 334TH LN APT D104
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8942
Mailing Address - Country:US
Mailing Address - Phone:425-891-7821
Mailing Address - Fax:
Practice Address - Street 1:3639 MARTIN LUTHER KING JR WAY S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-6847
Practice Address - Country:US
Practice Address - Phone:206-292-5714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA101715436Medicaid