Provider Demographics
NPI:1275919938
Name:DIZON, JESSICA MAE (PHARMD, MHA, BCPS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MAE
Last Name:DIZON
Suffix:
Gender:F
Credentials:PHARMD, MHA, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 SW 2ND AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-4769
Mailing Address - Country:US
Mailing Address - Phone:949-939-8148
Mailing Address - Fax:
Practice Address - Street 1:315 SW 5TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-1703
Practice Address - Country:US
Practice Address - Phone:503-416-3917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22590183500000X
OR0016037183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist