1710622840 NPI number — JACQUELYN KRISTEN TRUJILLO APRN-NP, RNFA

Table of content: JACQUELYN KRISTEN TRUJILLO APRN-NP, RNFA (NPI 1710622840)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710622840 NPI number — JACQUELYN KRISTEN TRUJILLO APRN-NP, RNFA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRUJILLO
Provider First Name:
JACQUELYN
Provider Middle Name:
KRISTEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN-NP, RNFA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710622840
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5220 BELFORT RD STE 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32256-6018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-446-3701
Provider Business Mailing Address Fax Number:
904-446-3032

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
375 SE NORTON LN STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCMINNVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97128-8484
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-472-5749
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WR0006X , with the licence number:  201041838RN , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 10001033 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)