Provider Demographics
NPI:1215078050
Name:GILLIS, JENIFER T (PA-C)
Entity type:Individual
Prefix:
First Name:JENIFER
Middle Name:T
Last Name:GILLIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:JENIFER
Other - Middle Name:T
Other - Last Name:RIFENBERY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1145 BROADWAY FL 2
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-4201
Mailing Address - Country:US
Mailing Address - Phone:206-329-1760
Mailing Address - Fax:
Practice Address - Street 1:1812 S J ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4964
Practice Address - Country:US
Practice Address - Phone:253-752-6965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10002657363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1215078050Medicaid