Provider Demographics
NPI:1417574807
Name:IBSIES, JWANA B (CCP)
Entity Type:Individual
Prefix:MRS
First Name:JWANA
Middle Name:B
Last Name:IBSIES
Suffix:
Gender:F
Credentials:CCP
Other - Prefix:MRS
Other - First Name:JWANA
Other - Middle Name:
Other - Last Name:JABR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCP
Mailing Address - Street 1:12866 SW MORNINGSTAR DR
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-1784
Mailing Address - Country:US
Mailing Address - Phone:503-505-2373
Mailing Address - Fax:
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:503-505-2373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR089004242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist