Basic Information
| Provider Information | |||||||||
| NPI: | 1477279040 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINNIS | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7246 SW WOODBURY LOOP | ||||||||
| Address2: | |||||||||
| City: | WILSONVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970706902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039603796 | ||||||||
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| Practice Location | |||||||||
| Address1: | 222 SE 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971234218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033526151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2022 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program | 124Q00000X | N | Dental Providers | Dental Hygienist |
No ID Information.