Provider Demographics
NPI:1083709950
Name:MAIBEN, JESSAMINE MICHELLE
Entity Type:Individual
Prefix:
First Name:JESSAMINE
Middle Name:MICHELLE
Last Name:MAIBEN
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 1:906 CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-1239
Mailing Address - Country:US
Mailing Address - Phone:503-267-1347
Mailing Address - Fax:
Practice Address - Street 1:19400 NW EVERGREEN PKWY
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-7031
Practice Address - Country:US
Practice Address - Phone:503-690-5005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens