Provider Demographics
NPI:1093804536
Name:SEMMELROTH, JENNIFER SARA (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SARA
Last Name:SEMMELROTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 NE 19TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:9701 SW BARNES RD
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6772
Practice Address - Country:US
Practice Address - Phone:503-297-8081
Practice Address - Fax:503-292-6601
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01085363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
911019392OtherCOMMERCIAL
WA2039355Medicaid
OR500605524Medicaid
OR00834454OtherMEDICARE RAILROAD
OR00834454OtherMEDICARE RAILROAD
911019392OtherCOMMERCIAL
OR14109Medicare PIN
P52263Medicare UPIN