Healthcare Provider Details

I. General information

NPI: 1235823857
Provider Name (Legal Business Name): JADE FUNTANILLA KEKAUALUA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9205 SW BARNES RD STE 861
PORTLAND OR
97225-6603
US

IV. Provider business mailing address

9205 SW BARNES RD STE 861
PORTLAND OR
97225-6603
US

V. Phone/Fax

Practice location:
  • Phone: 503-216-1234
  • Fax:
Mailing address:
  • Phone: 503-216-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10018910
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: