Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103G00000X | Clinical Psychologist | PY60319475 | WA |
N | 103TC0700X | Clinical Psychologist | PY60319475 | WA |
Y | 103TC2200X | Clinical Child & Adolescent Psychologist | PY60319475 | WA |
NPI | 1063853596 |
---|---|
Provider Name | Jennifer Gerdts |
First Address | Seattle, WA 98105-3901 |
Second Address | Seattle, WA 98105-3901 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2013 |
Last Update Date | 09/01/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1063853596 | (05) | WA |