Provider Demographics
NPI:1063675346
Name:ENGSTROM, JENNIFER G (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:G
Last Name:ENGSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RUTH
Other - Last Name:GRACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-366-2983
Mailing Address - Fax:
Practice Address - Street 1:11603 STATE AVE
Practice Address - Street 2:STE G
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98271-8465
Practice Address - Country:US
Practice Address - Phone:360-658-6800
Practice Address - Fax:360-658-6819
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60021576207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD60021576OtherWSL
WAG8900436Medicare PIN