Provider Demographics
NPI:1417185190
Name:ANDERSON, JEAN (RN)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 SW OAK ST
Mailing Address - Street 2:#210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1817
Mailing Address - Country:US
Mailing Address - Phone:503-988-3056
Mailing Address - Fax:503-988-3015
Practice Address - Street 1:421 SW OAK ST
Practice Address - Street 2:#210
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-1817
Practice Address - Country:US
Practice Address - Phone:503-988-3056
Practice Address - Fax:503-988-3015
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR075034682RN163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022959Medicaid
OR096511Medicaid