Provider Demographics
NPI:1578321352
Name:TEETER, JACEY LYNN (BSN, RN)
Entity Type:Individual
Prefix:
First Name:JACEY
Middle Name:LYNN
Last Name:TEETER
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 165
Mailing Address - Street 2:
Mailing Address - City:IMBLER
Mailing Address - State:OR
Mailing Address - Zip Code:97841-0165
Mailing Address - Country:US
Mailing Address - Phone:541-910-6517
Mailing Address - Fax:
Practice Address - Street 1:1305 N WILLOW ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-3822
Practice Address - Country:US
Practice Address - Phone:541-663-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202007340RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse