Provider Demographics
NPI:1851760904
Name:WONG, JAMIE (FNP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:WONG
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 1:18040 SW LOWER BOONES FERRY RD
Practice Address - Street 2:STE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97224-7258
Practice Address - Country:US
Practice Address - Phone:503-216-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200842437RN163W00000X
OR20150712NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500693425Medicaid
ORR184419Medicare PIN
ORR184418Medicare PIN
ORR184415Medicare PIN
ORR184416Medicare PIN
OR500693425Medicaid
ORR184414Medicare PIN