Basic Information
| Provider Information | |||||||||
| NPI: | 1497764229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OPFERMAN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | TATE | ||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TATE | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | BETH | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3002 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986320302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607475800 | ||||||||
| FaxNumber: | 3605753846 | ||||||||
| Practice Location | |||||||||
| Address1: | 1718 E KESSLER BLVD | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986321842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607475800 | ||||||||
| FaxNumber: | 3605753846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 03/27/2013 | ||||||||
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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 | 363A00000X | PA10005022 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8942375 | 01 | WA | CRIME VICTIMS WA STATE | OTHER | P00341341 | 01 | RR MEDICARE | OTHER | 0212503 | 01 | WA | LABOR & IND. WA STATE | OTHER | 8461782 | 05 | WA | MEDICAID |