Provider Demographics
NPI:1518050459
Name:HANSEN, JILL R (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:R
Last Name:HANSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 NW 22ND AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2900
Mailing Address - Country:US
Mailing Address - Phone:503-413-8988
Mailing Address - Fax:503-274-4815
Practice Address - Street 1:1130 NW 22ND AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2900
Practice Address - Country:US
Practice Address - Phone:503-413-8988
Practice Address - Fax:503-274-4815
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23299207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR240276Medicaid
WA8484156Medicaid
OR240276Medicaid
OR135602Medicare PIN
OR135601Medicare PIN
WA8484156Medicaid