Basic Information
| Provider Information | |||||||||
| NPI: | 1912365347 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YEALY | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3777 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034133900 | ||||||||
| FaxNumber: | 5034133710 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | LURAY | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407434561 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2016 | ||||||||
| LastUpdateDate: | 07/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0110005197 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA187741 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.