Provider Demographics
NPI:1831139641
Name:EVANS, JACQUELINE P (CRNA, ARNP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:P
Last Name:EVANS
Suffix:
Gender:F
Credentials:CRNA, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1143
Mailing Address - Street 2:
Mailing Address - City:FALL CITY
Mailing Address - State:WA
Mailing Address - Zip Code:98024-1143
Mailing Address - Country:US
Mailing Address - Phone:425-830-5574
Mailing Address - Fax:
Practice Address - Street 1:6520 226TH PL SE
Practice Address - Street 2:STE 120
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-7371
Practice Address - Country:US
Practice Address - Phone:425-830-5574
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2019-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30001334367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA380452001OtherGROUP HEALTH
WA040217OtherLABOR & INDUSTRY
WA9611047Medicaid
WAEV3488OtherREGENCE BLUE CROSS/SHIELD