Healthcare Provider Details

I. General information

NPI: 1235539594
Provider Name (Legal Business Name): JACQUELINE SAMMONS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2014
Last Update Date: 06/11/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 NW BETHANY BLVD
BEAVERTON OR
97006-5208
US

IV. Provider business mailing address

14757 SW OREGON TRAIL LN
BEAVERTON OR
97006-5908
US

V. Phone/Fax

Practice location:
  • Phone: 303-868-3249
  • Fax:
Mailing address:
  • Phone: 303-868-3249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201405286NP-PP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201405286NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: