Provider Demographics
NPI:1497754329
Name:PAIRISH-LACK, JERI (CFNP)
Entity Type:Individual
Prefix:MS
First Name:JERI
Middle Name:
Last Name:PAIRISH-LACK
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 NW MIDLAND AVE
Mailing Address - Street 2:STE J
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1269
Mailing Address - Country:US
Mailing Address - Phone:541-476-8859
Mailing Address - Fax:541-955-8611
Practice Address - Street 1:124 NW MIDLAND AVE
Practice Address - Street 2:STE J
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1269
Practice Address - Country:US
Practice Address - Phone:541-476-8859
Practice Address - Fax:541-955-8611
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR094006084N1363LF0000X
OR207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000473Medicaid
ORP55065Medicare UPIN
OR000473Medicaid