Provider Demographics
NPI:1407345283
Name:MACDOUGALL, JESSICA DALE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DALE
Last Name:MACDOUGALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-4300
Mailing Address - Fax:503-494-4323
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-4300
Practice Address - Fax:503-494-4323
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC238201390200000X
ORMD216054207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program