Provider Demographics
NPI:1154471928
Name:RICHARDSON, JEANNIE LYNN (RN)
Entity Type:Individual
Prefix:MS
First Name:JEANNIE
Middle Name:LYNN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4588 SWEGLE RD NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2012
Mailing Address - Country:US
Mailing Address - Phone:503-371-6739
Mailing Address - Fax:503-763-2419
Practice Address - Street 1:4590 SWEGLE RD NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2012
Practice Address - Country:US
Practice Address - Phone:503-371-6739
Practice Address - Fax:503-763-2419
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR098051Medicaid