Basic Information
| Provider Information | |||||||||
| NPI: | 1972589976 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLINGHAM | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51377 SW OLD PORTLAND RD | ||||||||
| Address2: | |||||||||
| City: | SCAPPOOSE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970564023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034184222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 51377 SW OLD PORTLAND RD | ||||||||
| Address2: | |||||||||
| City: | SCAPPOOSE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970564023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034184222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 05/19/2017 | ||||||||
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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 | 207Q00000X | 0420010400 | VT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD181506 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1008992 | 05 | VT | MEDICAID | 58976 | 01 | VT | BLUE CROSS BLUE SHIELD | OTHER | 365938 | 01 | VT | MVP | OTHER | 58976 | 01 | VT | VERMONT MANAGED CARE | OTHER |