Healthcare Provider Details

I. General information

NPI: 1831475409
Provider Name (Legal Business Name): JERI N RUDOLF CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2011
Last Update Date: 11/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 M AVE SUITE G
ANACORTES WA
98221-3897
US

IV. Provider business mailing address

1211 24TH ST
ANACORTES WA
98221-2562
US

V. Phone/Fax

Practice location:
  • Phone: 360-299-4297
  • Fax: 360-299-4294
Mailing address:
  • Phone: 360-299-4297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP60483318
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP 01867
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: