Provider Demographics
NPI:1962521435
Name:CASERTA, JENNIFER (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CASERTA
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 1:1911 COOKS HILL RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9073
Mailing Address - Country:US
Mailing Address - Phone:360-736-6778
Mailing Address - Fax:360-736-6552
Practice Address - Street 1:1911 COOKS HILL RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9073
Practice Address - Country:US
Practice Address - Phone:360-736-6778
Practice Address - Fax:360-736-6552
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043677208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2914CAOtherREGENCE
WA9116CAOtherREGENCE
WA230532008OtherGROUP HEALTH
WA7122617Medicaid
WA7057375Medicaid
WA7131709Medicaid
WA7131717Medicaid
WA8398356Medicaid