Provider Demographics
NPI:1295130516
Name:JENNINGS, JONATHAN CHRISTIAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:CHRISTIAN
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE
Mailing Address - Street 2:DEPT. 358
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9324
Mailing Address - Country:US
Mailing Address - Phone:360-729-1462
Mailing Address - Fax:360-729-3104
Practice Address - Street 1:1718 E KESSLER BLVD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-1842
Practice Address - Country:US
Practice Address - Phone:360-747-5800
Practice Address - Fax:360-575-3846
Is Sole Proprietor?:No
Enumeration Date:2014-10-29
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60514742363A00000X
COPA.0004564363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant