Provider Demographics
NPI:1982040291
Name:TRUSSELL, JACQUELINE (AGACNP-BC, FNP-BC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:TRUSSELL
Suffix:
Gender:F
Credentials:AGACNP-BC, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3485 S BOND AVE, BUILDING 2
Mailing Address - Street 2:11TH FLOOR
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4503
Mailing Address - Country:US
Mailing Address - Phone:503-494-5058
Mailing Address - Fax:
Practice Address - Street 1:3485 S BOND AVE, BUILDING 2
Practice Address - Street 2:11TH FLOOR
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-494-5058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2023-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201350101NP363LF0000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily