Provider Demographics
NPI:1275706103
Name:EGAN, JENNIFER CAROLINE MARTIN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:CAROLINE MARTIN
Last Name:EGAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:ELLEN CAROLINE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NONE
Mailing Address - Street 1:3395 SW 86TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-2820
Mailing Address - Country:US
Mailing Address - Phone:503-292-1717
Mailing Address - Fax:
Practice Address - Street 1:3395 SW 86TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-2820
Practice Address - Country:US
Practice Address - Phone:503-292-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20083004LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse