Provider Demographics
NPI:1902405582
Name:REARDON, JENNIFER LEIGH
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEIGH
Last Name:REARDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33785 SE DAVONA DR
Mailing Address - Street 2:
Mailing Address - City:SCAPPOOSE
Mailing Address - State:OR
Mailing Address - Zip Code:97056-4513
Mailing Address - Country:US
Mailing Address - Phone:503-307-6834
Mailing Address - Fax:
Practice Address - Street 1:33785 SE DAVONA DR
Practice Address - Street 2:
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056-4513
Practice Address - Country:US
Practice Address - Phone:503-307-6834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60699055163WH0200X
OR200441874163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care
No163WH0200XNursing Service ProvidersRegistered NurseHome Health