Provider Demographics
NPI:1922376557
Name:MCLAIN, JACOB ANDRE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:ANDRE
Last Name:MCLAIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3736 SE CORA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3238
Mailing Address - Country:US
Mailing Address - Phone:503-756-7070
Mailing Address - Fax:
Practice Address - Street 1:3736 SE CORA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3238
Practice Address - Country:US
Practice Address - Phone:503-756-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-10
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201394848CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered