Provider Demographics
NPI:1033190574
Name:HANLON-WILDE, JENNIFER (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:HANLON-WILDE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:HANLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 1520
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-8003
Mailing Address - Country:US
Mailing Address - Phone:541-296-5657
Mailing Address - Fax:
Practice Address - Street 1:1810 E 19TH ST
Practice Address - Street 2:SUITE 209
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3388
Practice Address - Country:US
Practice Address - Phone:541-296-5657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR098006694NP363LF0000X
OR098006694RN FNP-PP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR092586Medicaid
ORR120811Medicare ID - Type Unspecified
OR092586Medicaid