Provider Demographics
NPI:1619482551
Name:OFFUTT, JENNESSA VICTORIA (FNP)
Entity Type:Individual
Prefix:MISS
First Name:JENNESSA
Middle Name:VICTORIA
Last Name:OFFUTT
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 4825
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4825
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:360-604-1770
Practice Address - Street 1:700 NE 87TH AVE # 260
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1913
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60882886363LP2300X
WAAP60882886363LF0000X
WARN60651055163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2134328Medicaid