Provider Demographics
NPI:1790242816
Name:ROURKE, JENNIFER MARIE (APRN CNS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:ROURKE
Suffix:
Gender:F
Credentials:APRN CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 S SEQUOIA PKWY # I080
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-7836
Mailing Address - Country:US
Mailing Address - Phone:503-314-3416
Mailing Address - Fax:
Practice Address - Street 1:3710 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2964
Practice Address - Country:US
Practice Address - Phone:503-314-3416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201808311CNS-PP364SC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine