Healthcare Provider Details

I. General information

NPI: 1629494505
Provider Name (Legal Business Name): JILL YOSHIKO YUZURIHA FAJARDO O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL YOSHIKO YUZURIHA

II. Dates (important events)

Enumeration Date: 03/14/2014
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 SE 164TH AVE STE 102
VANCOUVER WA
98683-9644
US

IV. Provider business mailing address

1405 SE 164TH AVE STE 102
VANCOUVER WA
98683-9644
US

V. Phone/Fax

Practice location:
  • Phone: 360-253-4405
  • Fax: 360-823-0035
Mailing address:
  • Phone: 360-253-4405
  • Fax: 360-823-0035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number15003TLG
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number61666052
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: