Provider Demographics
NPI:1669467304
Name:SOMMERVILLE, JEANINE ANN (MD)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:ANN
Last Name:SOMMERVILLE
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:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:13020 MERIDIAN AVE S
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-6468
Practice Address - Country:US
Practice Address - Phone:425-357-3700
Practice Address - Fax:425-357-3701
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60011389207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2001402Medicaid
WAG8878071Medicare PIN
WA8508426Medicaid