Provider Demographics
NPI:1669875993
Name:LONGWAY, JILLIAN C S (CPNP)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:C S
Last Name:LONGWAY
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:C
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:1628 S MILDRED ST STE 101
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98465-1628
Mailing Address - Country:US
Mailing Address - Phone:253-564-8005
Mailing Address - Fax:
Practice Address - Street 1:1628 S MILDRED ST STE 101
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98465-1628
Practice Address - Country:US
Practice Address - Phone:253-564-8005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60840002163W00000X
WAAP60849416363LP0200X, 363LP0200X
PASP017177363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse