Provider Demographics
NPI:1255778239
Name:PONTAROLO, JENNIFER KOHNLEIN (DO)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:KOHNLEIN
Last Name:PONTAROLO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2473
Mailing Address - Country:US
Mailing Address - Phone:509-574-6175
Mailing Address - Fax:509-573-6275
Practice Address - Street 1:1806 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2473
Practice Address - Country:US
Practice Address - Phone:509-574-6175
Practice Address - Fax:509-573-6275
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOL60376336207Q00000X
WAOP60494165207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2029861Medicaid
WAAB38059Medicare Oscar/Certification