Provider Demographics
NPI:1275301897
Name:CROSS, JEROME
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:CROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JEROME
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:232 NW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33 NW BROADWAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3580
Practice Address - Country:US
Practice Address - Phone:503-228-7134
Practice Address - Fax:503-501-5679
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22-CRM-1117175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist