Provider Demographics
NPI:1346289923
Name:MEHTA, JESSICA N (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:N
Last Name:MEHTA
Suffix:
Gender:F
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:18040 SW LOWER BOONES FERRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7258
Practice Address - Country:US
Practice Address - Phone:503-216-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26617207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00468706OtherRR MEDICARE
OR028278Medicaid
ORP00443453OtherRR MEDICARE
OR028278Medicaid
ORR143082Medicare PIN
ORR146566Medicare PIN
ORR136166Medicare PIN