Provider Demographics
NPI:1144497736
Name:MULLIS GRANT, JENNIFER MARIE (PA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:MULLIS GRANT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 1517
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-0410
Mailing Address - Country:US
Mailing Address - Phone:877-708-1119
Mailing Address - Fax:541-278-8349
Practice Address - Street 1:1420 JOHN ADAMS ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1609
Practice Address - Country:US
Practice Address - Phone:503-656-1484
Practice Address - Fax:503-650-1976
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005270363A00000X
ORPA212952363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant