Provider Demographics
NPI:1891047130
Name:JAMESON, IAN
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:JAMESON
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 1:2508 PACIFIC AVE
Mailing Address - Street 2:APT. #2
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-2377
Mailing Address - Country:US
Mailing Address - Phone:208-351-7245
Mailing Address - Fax:
Practice Address - Street 1:2508 PACIFIC AVE
Practice Address - Street 2:APT. #2
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2377
Practice Address - Country:US
Practice Address - Phone:208-351-7245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program