Provider Demographics
NPI:1114033610
Name:ROSEVELT, JANE
Entity Type:Individual
Prefix:MS
First Name:JANE
Middle Name:
Last Name:ROSEVELT
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 1:16300 SUNRISE CT
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4316
Mailing Address - Country:US
Mailing Address - Phone:503-635-8834
Mailing Address - Fax:
Practice Address - Street 1:3550 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1196
Practice Address - Country:US
Practice Address - Phone:503-285-9321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner