Provider Demographics
NPI:1578513651
Name:KOOSMAN, JEFFREY ALLEN (DC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALLEN
Last Name:KOOSMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 SE OAK ST
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4240
Mailing Address - Country:US
Mailing Address - Phone:503-648-6997
Mailing Address - Fax:503-648-0122
Practice Address - Street 1:862 SE OAK
Practice Address - Street 2:SUITE 3A
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123
Practice Address - Country:US
Practice Address - Phone:503-648-6997
Practice Address - Fax:503-648-0122
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1807111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000QGCPFMedicare ID - Type Unspecified