Provider Demographics
NPI:1134438039
Name:CHILDRESS, JENNIFER T (CPM LDM)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:T
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:CPM LDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40660 NORTHFORK RD
Mailing Address - Street 2:
Mailing Address - City:NEHALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97131-9511
Mailing Address - Country:US
Mailing Address - Phone:503-368-5886
Mailing Address - Fax:503-368-5886
Practice Address - Street 1:40660 NORTHFORK RD
Practice Address - Street 2:
Practice Address - City:NEHALEM
Practice Address - State:OR
Practice Address - Zip Code:97131-9511
Practice Address - Country:US
Practice Address - Phone:503-368-5886
Practice Address - Fax:503-368-5886
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDEM-LD-10143021176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife