Provider Demographics
NPI:1992772412
Name:KAE, JACQUELIN (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELIN
Middle Name:
Last Name:KAE
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 1:3633 PACIFIC AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-7900
Mailing Address - Country:US
Mailing Address - Phone:253-274-1668
Mailing Address - Fax:
Practice Address - Street 1:3633 PACIFIC AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-7900
Practice Address - Country:US
Practice Address - Phone:253-274-1668
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA26924207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8407462Medicaid
WAE29288Medicare UPIN
WA8850161Medicare ID - Type Unspecified