Provider Demographics
NPI:1174678429
Name:JAHNKE, JONATHAN D (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:JAHNKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 E HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-2825
Mailing Address - Country:US
Mailing Address - Phone:503-538-2020
Mailing Address - Fax:503-554-9549
Practice Address - Street 1:307 E HANCOCK ST
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-2825
Practice Address - Country:US
Practice Address - Phone:503-538-2020
Practice Address - Fax:503-554-9549
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14241174400000X
OR332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR142216Medicaid
OR142216Medicaid
OR0428130001Medicare NSC
ORR0000BHWCZMedicare PIN