Provider Demographics
NPI:1902902018
Name:KIM-DEOBALD, JESSIE (MD)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:KIM-DEOBALD
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 1:1530 N 115TH ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-8411
Mailing Address - Country:US
Mailing Address - Phone:206-365-5000
Mailing Address - Fax:206-365-5002
Practice Address - Street 1:1530 N 115TH ST
Practice Address - Street 2:SUITE 301
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-8411
Practice Address - Country:US
Practice Address - Phone:206-365-5000
Practice Address - Fax:206-365-5002
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1093699Medicaid
WA5355KIOtherREGENCE RYDER NUMBER
WAG10594Medicare UPIN