Provider Demographics
NPI:1568729820
Name:BORMUTH, JENNIFER LEIGH (MS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
Last Name:BORMUTH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEIGH
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:621 W MADRONE ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-3090
Mailing Address - Country:US
Mailing Address - Phone:541-440-3655
Mailing Address - Fax:
Practice Address - Street 1:621 W MADRONE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3090
Practice Address - Country:US
Practice Address - Phone:541-440-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker