Provider Demographics
NPI:1518751247
Name:INOCENCIO, JESSICA LYNN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:INOCENCIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMUEL
Other - Middle Name:LYNN
Other - Last Name:INOCENCIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8284 28TH CT NE STE A
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-7161
Mailing Address - Country:US
Mailing Address - Phone:360-915-3221
Mailing Address - Fax:
Practice Address - Street 1:8284 28TH CT NE STE A
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-7161
Practice Address - Country:US
Practice Address - Phone:360-915-3221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program