Provider Demographics
NPI:1053307645
Name:SNOW, JERROLD L (DO)
Entity Type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:L
Last Name:SNOW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6564 SE LAKE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2237
Mailing Address - Country:US
Mailing Address - Phone:503-908-5880
Mailing Address - Fax:888-475-8729
Practice Address - Street 1:6564 SE LAKE RD STE 200
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222
Practice Address - Country:US
Practice Address - Phone:503-908-5880
Practice Address - Fax:888-475-8729
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD017285207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR033840Medicaid
OR08WCJXLEMedicare ID - Type Unspecified
OR033840Medicaid