Provider Demographics
NPI:1003061292
Name:MURILLO, JACQUELYN ROSE (FNP)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ROSE
Last Name:MURILLO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:421 SW OAK ST
Mailing Address - Street 2:STE.210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1817
Mailing Address - Country:US
Mailing Address - Phone:503-988-3663
Mailing Address - Fax:503-988-3015
Practice Address - Street 1:25742 104TH AVE SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7691
Practice Address - Country:US
Practice Address - Phone:206-263-0540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60866630363L00000X
OR200741787RN163W00000X
OR200950072NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22959Medicaid
ORR0000WCJHTMedicare Oscar/Certification