Provider Demographics
NPI:1518973015
Name:NELSON, JENNIFER PENFIELD (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PENFIELD
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:PENFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1945 NE JAMIE DR.
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124
Mailing Address - Country:US
Mailing Address - Phone:503-679-9460
Mailing Address - Fax:971-327-4356
Practice Address - Street 1:2111 NE 25TH AVE INTEL HEALTH FOR LIFE CENTER
Practice Address - Street 2:MS:JF-167
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124
Practice Address - Country:US
Practice Address - Phone:503-264-8315
Practice Address - Fax:503-264-0559
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00813363A00000X
OR00813363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500617236Medicaid
OR500617236Medicaid
ORR168967Medicare PIN