Provider Demographics
NPI:1063485423
Name:MICEK, JENNIFER L (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:MICEK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:NITZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:530 NW 27TH ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-5223
Mailing Address - Country:US
Mailing Address - Phone:541-766-6835
Mailing Address - Fax:541-766-6186
Practice Address - Street 1:530 NW 27TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-5223
Practice Address - Country:US
Practice Address - Phone:541-766-6835
Practice Address - Fax:541-766-6186
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO25970207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR168395Medicaid
R103163OtherMEDICARE PART B
I42936Medicare UPIN
OR168395Medicaid
R103163Medicare Oscar/Certification
132795Medicare PIN