Provider Demographics
NPI:1265684187
Name:JASPERSE, KENNETH (AA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:JASPERSE
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12031 SE MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-3963
Mailing Address - Country:US
Mailing Address - Phone:503-666-3808
Mailing Address - Fax:503-666-6835
Practice Address - Street 1:4101 NE DIVISION ST # 100
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-4617
Practice Address - Country:US
Practice Address - Phone:503-666-3808
Practice Address - Fax:503-666-6835
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist