Provider Demographics
NPI:1164576617
Name:JONES, GWYNETH THERESA (DNP, FNP)
Entity Type:Individual
Prefix:
First Name:GWYNETH
Middle Name:THERESA
Last Name:JONES
Suffix:
Gender:F
Credentials:DNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 SE 81ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1534
Mailing Address - Country:US
Mailing Address - Phone:503-734-5487
Mailing Address - Fax:
Practice Address - Street 1:1410 NE 106TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3934
Practice Address - Country:US
Practice Address - Phone:503-460-0405
Practice Address - Fax:503-460-0434
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 372600000X
OR201506920NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No372600000XNursing Service Related ProvidersAdult Companion