Provider Demographics
NPI:1366252736
Name:EBERSOLE, JEAN
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:EBERSOLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 WATER ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-8040
Mailing Address - Country:US
Mailing Address - Phone:717-271-4823
Mailing Address - Fax:
Practice Address - Street 1:1020 ANDERSON DR STE 203
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-1055
Practice Address - Country:US
Practice Address - Phone:360-533-6063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61615826363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily