Provider Demographics
NPI:1316920648
Name:LUTHER, JEANNETTE V (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JEANNETTE
Middle Name:V
Last Name:LUTHER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1718 E KESSLER BLVD
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-747-5800
Mailing Address - Fax:
Practice Address - Street 1:8507 S 5TH ST
Practice Address - Street 2:SUITE 113
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-3421
Practice Address - Country:US
Practice Address - Phone:360-887-9494
Practice Address - Fax:360-887-9498
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003342363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8320889Medicaid
WA8320889Medicaid