Provider Demographics
NPI:1134540941
Name:WILLIS, JENNIFER (MPAS, PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MPAS, 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 31001-4114
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-4114
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:509-227-7070
Practice Address - Street 1:217 W CATALDO AVE FL 3
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2217
Practice Address - Country:US
Practice Address - Phone:509-747-6194
Practice Address - Fax:509-838-0824
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-20
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA0275363AM0700X
WAPA61230443363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical