Provider Demographics
NPI:1528006921
Name:NIELSEN, JO ANNE (MD)
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:ANNE
Last Name:NIELSEN
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 1:19069 S PIONEER CROSSING LN
Mailing Address - Street 2:
Mailing Address - City:ESTACADA
Mailing Address - State:OR
Mailing Address - Zip Code:97023-9687
Mailing Address - Country:US
Mailing Address - Phone:503-631-7087
Mailing Address - Fax:
Practice Address - Street 1:14279 GLEN OAK RD
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-8008
Practice Address - Country:US
Practice Address - Phone:503-657-7629
Practice Address - Fax:503-557-8651
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14362208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3323000OtherBCBS
OR128553Medicaid
OR128553Medicaid