Healthcare Provider Details

I. General information

NPI: 1609255595
Provider Name (Legal Business Name): JENNIFER ELAINE LOCKWOOD AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2015
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NE 87TH AVE STE 460
VANCOUVER WA
98664-1965
US

IV. Provider business mailing address

847 NE 19TH AVE STE 300
PORTLAND OR
97232-2686
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-7771
  • Fax: 360-514-7769
Mailing address:
  • Phone: 503-963-2801
  • Fax: 503-963-2825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number632123
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95003105
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number201802036NP-PP
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP60833511
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: