Provider Demographics
NPI:1003659590
Name:JAGGER & CREW INTERNATIONAL LLC
Entity type:Organization
Organization Name:JAGGER & CREW INTERNATIONAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-571-5012
Mailing Address - Street 1:1166 E WARNER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1975 NW 167TH PL STE 100-11
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4908
Practice Address - Country:US
Practice Address - Phone:971-571-5012
Practice Address - Fax:971-233-6448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-13
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty