Provider Demographics
NPI:1891184107
Name:TRUMBO, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:TRUMBO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7415 NE 94TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-3859
Mailing Address - Country:US
Mailing Address - Phone:360-253-6019
Mailing Address - Fax:360-253-2698
Practice Address - Street 1:7415 NE 94TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-3859
Practice Address - Country:US
Practice Address - Phone:360-253-6019
Practice Address - Fax:360-253-2698
Is Sole Proprietor?:No
Enumeration Date:2015-01-10
Last Update Date:2015-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN 60471626163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse