Basic Information
| Provider Information | |||||||||
| NPI: | 1720586977 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUCE | ||||||||
| FirstName: | JENEECA | ||||||||
| MiddleName: | CHRISTINA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MEDICAL STUDENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3360 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4112 HARBOUR POINTE BLVD SW STE 100 | ||||||||
| Address2: | |||||||||
| City: | MUKILTEO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982755457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253476330 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2018 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | AZ | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | OP61185995 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.