Provider Demographics
NPI:1124416722
Name:JRN LAKE O PC
Entity type:Organization
Organization Name:JRN LAKE O PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:RICHMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-504-6692
Mailing Address - Street 1:17050 PILKINGTON RD STE 130
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-6308
Mailing Address - Country:US
Mailing Address - Phone:503-697-3255
Mailing Address - Fax:503-697-7792
Practice Address - Street 1:10690 NE CORNELL RD STE 324
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-9224
Practice Address - Country:US
Practice Address - Phone:503-297-9340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-05
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25244208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty