Provider Demographics
NPI:1821706862
Name:WILD HEART NATURAL MEDICINE LLC
Entity Type:Organization
Organization Name:WILD HEART NATURAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NATUROPATHIC PHYSICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:503-757-6686
Mailing Address - Street 1:5215 SW 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-1176
Mailing Address - Country:US
Mailing Address - Phone:503-757-6686
Mailing Address - Fax:
Practice Address - Street 1:5215 SW 62ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-1176
Practice Address - Country:US
Practice Address - Phone:503-757-6686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-08
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty