Provider Demographics
NPI:1356351688
Name:ANDERSON, JERRY M JR (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:M
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 TERRY AVE FL 8
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2735
Mailing Address - Country:US
Mailing Address - Phone:206-287-6300
Mailing Address - Fax:206-341-1250
Practice Address - Street 1:1201 TERRY AVE FL 8
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2735
Practice Address - Country:US
Practice Address - Phone:206-287-6300
Practice Address - Fax:206-341-1250
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5224207V00000X
WAMD60481560207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2044576Medicaid
TX161225101Medicaid
TX8F8791OtherBCBS
TX133275100OtherFIRST CARE
TXH83530Medicare UPIN
TX8A6783Medicare ID - Type Unspecified