Provider Demographics
NPI:1013040526
Name:OTTERSTROM, JERI LYNN (ND)
Entity Type:Individual
Prefix:DR
First Name:JERI
Middle Name:LYNN
Last Name:OTTERSTROM
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-3230
Mailing Address - Country:US
Mailing Address - Phone:541-688-1569
Mailing Address - Fax:541-461-4884
Practice Address - Street 1:1000 RIVER RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-3230
Practice Address - Country:US
Practice Address - Phone:541-688-1569
Practice Address - Fax:541-461-6884
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1162175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR229346Medicaid
OR43-1986773OtherTAX ID