Provider Demographics
NPI:1326056847
Name:BEVACQUA, JENNIFER E (PNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:BEVACQUA
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 SW OAK ST
Mailing Address - Street 2:STE 210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1817
Mailing Address - Country:US
Mailing Address - Phone:503-988-3663
Mailing Address - Fax:503-988-3015
Practice Address - Street 1:600 NE 8TH ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7317
Practice Address - Country:US
Practice Address - Phone:503-988-5155
Practice Address - Fax:503-988-5185
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200550067NP363LP0200X
OR200041072RN363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR270026Medicaid
OR270026Medicaid