Provider Demographics
NPI:1124078407
Name:ALLRED, JENNIFER EMMA
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:EMMA
Last Name:ALLRED
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:EMMA
Other - Last Name:ROMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2045
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4527
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2045
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4527
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK908163WG0000X
OR086006061N3363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1407812365OtherGROUP NPI NORTH BEND MEDICAL CENTER
ORP01567261OtherRAILROAD MEDICARE
ORR0000WFBTVOtherGROUP MEDICARE NORTH BEND MEDICAL CENTER
OR93-0635514OtherGROUP TAX ID NORTH BEND MEDICAL CENTER
OR161133OtherGROUP DMAP NORTH BEND MEDICAL CENTER
OR500677191Medicaid
OR500677191Medicaid