Provider Demographics
NPI:1043921588
Name:EBY, JENNIFER NOEL
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NOEL
Last Name:EBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FLOR
Other - Middle Name:
Other - Last Name:EBY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1132 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1132 SW 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1703
Practice Address - Country:US
Practice Address - Phone:951-345-3854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000104943175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR175T00000XMedicaid