Provider Demographics
NPI:1508252263
Name:BALL, JENNIFER (RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BALL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97351-0012
Mailing Address - Country:US
Mailing Address - Phone:503-851-1662
Mailing Address - Fax:
Practice Address - Street 1:561 N GUN CLUB RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OR
Practice Address - Zip Code:97351-9631
Practice Address - Country:US
Practice Address - Phone:503-851-1662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200841190163W00000X
OR200841190RN163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163W00000XNursing Service ProvidersRegistered Nurse