Provider Demographics
NPI:1629034152
Name:BURNESS, JESSICA V (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:V
Last Name:BURNESS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:O
Other - Last Name:BURNESS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:10330 SE 32ND AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6587
Practice Address - Country:US
Practice Address - Phone:503-513-8950
Practice Address - Fax:503-513-8951
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24832207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00604895OtherRR MEDICARE
OR275143Medicaid
ORR138851Medicare PIN
I03078Medicare UPIN