Healthcare Provider Details

I. General information

NPI: 1679203988
Provider Name (Legal Business Name): JENNA LAWREY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2022
Last Update Date: 10/21/2023
Certification Date: 10/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2426 N MERRITT CREEK LOOP STE A
COEUR D ALENE ID
83814-4961
US

IV. Provider business mailing address

8610 N CAMPBELL RD
OTIS ORCHARDS WA
99027-9205
US

V. Phone/Fax

Practice location:
  • Phone: 208-819-2183
  • Fax:
Mailing address:
  • Phone: 509-808-0641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2607
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.PA.61479317
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: