Provider Demographics
NPI:1063456200
Name:NYBERG, JENNIFER L
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:NYBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3645 SNOWBERRY RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97403-3262
Mailing Address - Country:US
Mailing Address - Phone:541-908-2191
Mailing Address - Fax:
Practice Address - Street 1:1742 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-3710
Practice Address - Country:US
Practice Address - Phone:541-343-8449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27 3506111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213426Medicaid
OR120063Medicare ID - Type UnspecifiedPROVIDER IDENTIFICATION #
OR213426Medicaid
OR120061Medicare ID - Type UnspecifiedGROUP IDENTIFICATION #