Provider Demographics
NPI:1447432190
Name:RENNA, JEFFREY C (PAC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:C
Last Name:RENNA
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1793 13TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2541
Mailing Address - Country:US
Mailing Address - Phone:503-362-8385
Mailing Address - Fax:503-362-8435
Practice Address - Street 1:1610 12TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2821
Practice Address - Country:US
Practice Address - Phone:541-316-6575
Practice Address - Fax:541-210-8913
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60133630363AM0700X
ORPA 153839363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR384377Medicaid
OR384377Medicaid
WAG8890320Medicare PIN