Provider Demographics
NPI:1235539594
Name:SAMMONS, JACQUELINE (NP-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:SAMMONS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2237 NW EDGEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-7618
Mailing Address - Country:US
Mailing Address - Phone:303-868-3249
Mailing Address - Fax:
Practice Address - Street 1:17704 JEAN WAY
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5497
Practice Address - Country:US
Practice Address - Phone:503-675-6776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-23
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201405286NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily