Provider Demographics
NPI:1114205036
Name:KERSTETTER, JESSICA REISS (CNM)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:REISS
Last Name:KERSTETTER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7650 SW BEVELAND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8692
Mailing Address - Country:US
Mailing Address - Phone:503-855-1620
Mailing Address - Fax:503-840-3299
Practice Address - Street 1:10566 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2809
Practice Address - Country:US
Practice Address - Phone:503-734-3800
Practice Address - Fax:503-734-3808
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500637294Medicaid
ORR171436OtherMEDICARE PTAN