Provider Demographics
NPI:1467565671
Name:MAYBERRY, JENNIFER PURDY (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:PURDY
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:JENNIFER
Other - Last Name:PURDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:21874 NE PARK LANE
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97204
Mailing Address - Country:US
Mailing Address - Phone:503-253-1105
Mailing Address - Fax:503-535-8398
Practice Address - Street 1:233 NE 102ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220
Practice Address - Country:US
Practice Address - Phone:503-253-1105
Practice Address - Fax:503-535-8398
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD243762085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H86562Medicare UPIN
OR116179Medicare ID - Type Unspecified