Provider Demographics
NPI:1235476706
Name:DOUGLAS, JENNIFER (RN00123804)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:RN00123804
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AP60427024
Mailing Address - Street 1:PO BOX 1595
Mailing Address - Street 2:1520 KELLY PLACE, SUITE 220
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0329
Mailing Address - Country:US
Mailing Address - Phone:509-520-2924
Mailing Address - Fax:
Practice Address - Street 1:1520 KELLY PL STE 220
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-8607
Practice Address - Country:US
Practice Address - Phone:509-520-2924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-03
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00123804163WA2000X, 163WS0200X
WAAP60427024363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WS0200XNursing Service ProvidersRegistered NurseSchool