Provider Demographics
NPI:1902828536
Name:WELLNITZ, JILL KEITGES (PA-C)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:KEITGES
Last Name:WELLNITZ
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: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:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:5330 NE GLISAN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3069
Practice Address - Country:US
Practice Address - Phone:503-215-9080
Practice Address - Fax:503-215-9099
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01112363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500600088Medicaid
ORR153617Medicare PIN
ORR156964Medicare PIN
OR500600088Medicaid