Provider Demographics
NPI:1003516758
Name:JERDIN, JESSICA (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:JERDIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4103 MERCANTILE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-2556
Mailing Address - Country:US
Mailing Address - Phone:503-850-9940
Mailing Address - Fax:877-533-6717
Practice Address - Street 1:4103 MERCANTILE DR
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2556
Practice Address - Country:US
Practice Address - Phone:503-850-9940
Practice Address - Fax:877-533-6717
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2025-05-29
Deactivation Date:2023-08-01
Deactivation Code:
Reactivation Date:2024-07-09
Provider Licenses
StateLicense IDTaxonomies
ORPA224310363A00000X
363AS0400X
AZ10530363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500855147Medicaid