Provider Demographics
NPI:1245635283
Name:WAKUMELO, JENNIFER MONIQUE (EFDA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MONIQUE
Last Name:WAKUMELO
Suffix:
Gender:F
Credentials:EFDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17675 SW TV HWY
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006
Mailing Address - Country:US
Mailing Address - Phone:503-259-3160
Mailing Address - Fax:503-259-3169
Practice Address - Street 1:17675 SW TV HWY
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006
Practice Address - Country:US
Practice Address - Phone:503-259-3160
Practice Address - Fax:503-259-3169
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR118652126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant