Provider Demographics
NPI:1689848715
Name:THORNBURG, JOCLYN
Entity Type:Individual
Prefix:
First Name:JOCLYN
Middle Name:
Last Name:THORNBURG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15592 SE CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-4438
Mailing Address - Country:US
Mailing Address - Phone:503-656-2715
Mailing Address - Fax:
Practice Address - Street 1:12000 SW 49TH AVE
Practice Address - Street 2:HT206
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-7132
Practice Address - Country:US
Practice Address - Phone:503-977-4909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0557124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist