Provider Demographics
NPI:1922324896
Name:SIMON, JEAN EDSON
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:EDSON
Last Name:SIMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:EDSON
Other - Middle Name:
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BSRPH
Mailing Address - Street 1:13888 SE 119TH DR
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-6636
Mailing Address - Country:US
Mailing Address - Phone:503-698-6336
Mailing Address - Fax:
Practice Address - Street 1:1950 NE BURNSIDE RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7949
Practice Address - Country:US
Practice Address - Phone:503-674-8482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0010145183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist