Provider Demographics
NPI:1558553693
Name:CARLSON, JENNIFER JOHNSON (FNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JOHNSON
Last Name:CARLSON
Suffix:
Gender:F
Credentials:FNP
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1905 SE 164TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-8937
Practice Address - Country:US
Practice Address - Phone:360-836-3396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200750023NP363LF0000X
WAAP30007648363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9658154Medicaid
OR500601300Medicaid
WAG8951719Medicare PIN
OR500601300Medicaid
ORR187189Medicare PIN