Healthcare Provider Details

I. General information

NPI: 1174952139
Provider Name (Legal Business Name): JILL E FACCIA AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 NE 87TH AVE
VANCOUVER WA
98664
US

IV. Provider business mailing address

700 NE 87TH AVE
VANCOUVER WA
98664-1913
US

V. Phone/Fax

Practice location:
  • Phone: 360-882-2778
  • Fax: 360-604-1771
Mailing address:
  • Phone: 360-882-2778
  • Fax: 360-604-1771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP60755776
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: