Healthcare Provider Details

I. General information

NPI: 1477958494
Provider Name (Legal Business Name): JENNIFER KING FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2014
Last Update Date: 10/08/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 SW 4TH AVE UNIT 1
ONTARIO OR
97914-4566
US

IV. Provider business mailing address

215 E HAWAII AVE
NAMPA ID
83686-6011
US

V. Phone/Fax

Practice location:
  • Phone: 541-889-2668
  • Fax:
Mailing address:
  • Phone: 208-463-3244
  • Fax: 208-463-3338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP61055386
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberN-1512A
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201407668NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: