Provider Demographics
NPI:1568919694
Name:O'DONNELL, JENNIFER (RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:O'DONNELL
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 1:1472 BELLE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671-1111
Mailing Address - Country:US
Mailing Address - Phone:503-887-7588
Mailing Address - Fax:
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2367
Practice Address - Country:US
Practice Address - Phone:360-816-5706
Practice Address - Fax:360-696-5038
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201705913RN163W00000X
WARN60454019163W00000X
OR201901742NP-PP363L00000X
WAAP60934049363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse