Provider Demographics
NPI:1457848574
Name:HOLTTUM, JESSICA KIMBERLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:KIMBERLEY
Last Name:HOLTTUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7650 SW BEVELAND ST
Mailing Address - Street 2:STE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223
Mailing Address - Country:US
Mailing Address - Phone:503-855-1620
Mailing Address - Fax:503-840-3299
Practice Address - Street 1:1130 NW 22ND AVE STE 520
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2976
Practice Address - Country:US
Practice Address - Phone:503-274-4800
Practice Address - Fax:503-274-4917
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORMD209450207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program