Provider Demographics
NPI:1003489238
Name:BAUTISTA, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:BAUTISTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 MONMOUTH INDEPENDENCE HWY
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:OR
Mailing Address - Zip Code:97361-1730
Mailing Address - Country:US
Mailing Address - Phone:971-283-3664
Mailing Address - Fax:
Practice Address - Street 1:132 GLYNBROOK ST N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-5796
Practice Address - Country:US
Practice Address - Phone:971-227-9808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-24
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator