Provider Demographics
NPI:1881633477
Name:FLANNERY, JENNIFER W (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:W
Last Name:FLANNERY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 N H ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-2535
Mailing Address - Country:US
Mailing Address - Phone:360-537-6113
Mailing Address - Fax:360-537-6146
Practice Address - Street 1:915 ANDERSON DR
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-1006
Practice Address - Country:US
Practice Address - Phone:360-537-6113
Practice Address - Fax:360-537-6146
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004754363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8500126Medicaid
WAQ47358Medicare UPIN
WA8500126Medicaid