Provider Demographics
NPI:1174271605
Name:ROBERTSON, JEREMY DEAN (RN)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DEAN
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 DRAGON DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:OR
Mailing Address - Zip Code:97456-9604
Mailing Address - Country:US
Mailing Address - Phone:541-766-6000
Mailing Address - Fax:
Practice Address - Street 1:610 DRAGON DRIVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:OR
Practice Address - Zip Code:97456-9604
Practice Address - Country:US
Practice Address - Phone:541-766-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201242599RN163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201242599RNOtherOREGON STATE BOARD OF NURSING