Provider Demographics
NPI:1043401813
Name:SLACK, JENNIFER M (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:SLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1411 SW MORRISON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1945
Mailing Address - Country:US
Mailing Address - Phone:503-242-9850
Mailing Address - Fax:503-279-8157
Practice Address - Street 1:501 N GRAHAM ST STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1650
Practice Address - Country:US
Practice Address - Phone:503-249-5780
Practice Address - Fax:503-249-5788
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD27695207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000000OtherIN PROCESS