Provider Demographics
NPI:1376510149
Name:JONQUIL, SHARON GLASS (CNM)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:GLASS
Last Name:JONQUIL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2242 NE 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4030
Mailing Address - Country:US
Mailing Address - Phone:503-282-7651
Mailing Address - Fax:
Practice Address - Street 1:2800 N VANCOUVER AVE
Practice Address - Street 2:LEGACY MIDWIFERY CLINIC, STE 255
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1671
Practice Address - Country:US
Practice Address - Phone:503-413-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR089000405N5367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR138080OtherPTAN
OR129580Medicaid
ORR56995Medicare UPIN
OR130262Medicare ID - Type Unspecified