Provider Demographics
NPI:1447452826
Name:SOPKO, JENNIFER NICOLE (PA-C)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:SOPKO
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:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 NW HIGHWAY 101 STE A
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-3241
Practice Address - Country:US
Practice Address - Phone:541-996-7480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2024-07-26
Deactivation Date:2017-10-19
Deactivation Code:
Reactivation Date:2017-11-06
Provider Licenses
StateLicense IDTaxonomies
VT055.0031594363AM0700X
NY021537363A00000X
MEPA2342363AM0700X
ORPA218759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical