Provider Demographics
NPI:1619788502
Name:ANDERSON, JENNIFER LYNN (RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15713 W PINE BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:NINE MILE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:99026-8722
Mailing Address - Country:US
Mailing Address - Phone:509-994-0847
Mailing Address - Fax:
Practice Address - Street 1:15713 W PINE BLUFF RD
Practice Address - Street 2:
Practice Address - City:NINE MILE FALLS
Practice Address - State:WA
Practice Address - Zip Code:99026-8722
Practice Address - Country:US
Practice Address - Phone:509-994-0847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-18
Last Update Date:2025-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61180442163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse