Provider Demographics
NPI:1083964704
Name:BENNETT, JACQUELYN ALICE (RN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:ALICE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2333
Mailing Address - Country:US
Mailing Address - Phone:503-215-3738
Mailing Address - Fax:
Practice Address - Street 1:4540 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2333
Practice Address - Country:US
Practice Address - Phone:503-215-3738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200340760RN163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontology