Provider Demographics
NPI:1487960878
Name:SHOUP, JENNIFER CAROL (PAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CAROL
Last Name:SHOUP
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 S UNION AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1947
Mailing Address - Country:US
Mailing Address - Phone:253-752-6965
Mailing Address - Fax:253-759-6056
Practice Address - Street 1:11400 98TH AVE NE STE 200
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-4306
Practice Address - Country:US
Practice Address - Phone:360-220-2585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60178872363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant