Provider Demographics
NPI:1235176264
Name:ROSQUIST, JENNIFER L (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:ROSQUIST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1412
Mailing Address - Fax:360-729-3028
Practice Address - Street 1:4545 CORDATA PKWY STE 1F
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-7264
Practice Address - Country:US
Practice Address - Phone:360-752-5246
Practice Address - Fax:360-752-5679
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8402208000000X
WAMD00046745208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0229981OtherL&I AND CRIME VICTIMS
WA8455099Medicaid
WAG8872960Medicare PIN
WA8455099Medicaid