Provider Demographics
NPI:1528492592
Name:TRAIL, JENNIFER EVELYN (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:EVELYN
Last Name:TRAIL
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 1:20120 BALLINGER WAY NE SUITE B
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155
Mailing Address - Country:US
Mailing Address - Phone:206-858-5059
Mailing Address - Fax:949-385-9207
Practice Address - Street 1:13718 100TH AVE NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-5216
Practice Address - Country:US
Practice Address - Phone:425-814-4888
Practice Address - Fax:425-814-3788
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5472363A00000X
WAPA.60543660363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant