Provider Demographics
NPI:1518419704
Name:GAINES, JENNA HANNAH (AGACNP)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:HANNAH
Last Name:GAINES
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 SW 5TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5537
Mailing Address - Country:US
Mailing Address - Phone:503-494-8417
Mailing Address - Fax:503-494-4455
Practice Address - Street 1:335 SE 8TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4246
Practice Address - Country:US
Practice Address - Phone:503-681-1860
Practice Address - Fax:503-681-1606
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5009013363L00000X
OR201809756NP-PP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500759983Medicaid