Provider Demographics
NPI:1649607425
Name:KASSELMANN, JENNIFER RENEE (FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
Last Name:KASSELMANN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1793 13TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2541
Mailing Address - Country:US
Mailing Address - Phone:503-362-8385
Mailing Address - Fax:503-362-8435
Practice Address - Street 1:700 S 320TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-4691
Practice Address - Country:US
Practice Address - Phone:253-839-6550
Practice Address - Fax:503-362-8435
Is Sole Proprietor?:No
Enumeration Date:2013-10-11
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60605290363L00000X
AZAP5322363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1649607425OtherNPI
AZRN127264OtherRN
AZMK3067611OtherDEA
AZAP5322OtherADVANCED PRACTITIONER LICENSE