Provider Demographics
NPI:1003607300
Name:BURWELL, JACOB JAMES (CHW)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:JAMES
Last Name:BURWELL
Suffix:
Gender:M
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 SW WEST HILLS RD
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-3999
Mailing Address - Country:US
Mailing Address - Phone:970-819-5888
Mailing Address - Fax:
Practice Address - Street 1:211 SE CHAPMAN PL
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-1224
Practice Address - Country:US
Practice Address - Phone:541-791-6691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR108686172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker