1235476706 NPI number — MS. JENNIFER DOUGLAS RN00123804

Table of content: MS. JENNIFER DOUGLAS RN00123804 (NPI 1235476706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235476706 NPI number — MS. JENNIFER DOUGLAS RN00123804

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGLAS
Provider First Name:
JENNIFER
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN00123804
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOUGLAS
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
AP60427024
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1235476706
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1595
Provider Second Line Business Mailing Address:
1520 KELLY PLACE, SUITE 220
Provider Business Mailing Address City Name:
WALLA WALLA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99362-0329
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-520-2924
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1520 KELLY PL STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLA WALLA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99362-8607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-520-2924
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2013

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: 163WA2000X , with the licence number:  RN00123804 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WS0200X , with the licence number: RN00123804 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: AP60427024 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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