Provider Demographics
NPI:1679219067
Name:SUN, JAIRO EMANUEL
Entity Type:Individual
Prefix:
First Name:JAIRO
Middle Name:EMANUEL
Last Name:SUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3049 PEPPERIDGE CT
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-8649
Mailing Address - Country:US
Mailing Address - Phone:503-421-7270
Mailing Address - Fax:
Practice Address - Street 1:180 ATWATER ST N
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:OR
Practice Address - Zip Code:97361-1801
Practice Address - Country:US
Practice Address - Phone:503-421-7270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker