Provider Demographics
NPI:1184127763
Name:SISK, RIA JENAE (CRM)
Entity type:Individual
Prefix:
First Name:RIA
Middle Name:JENAE
Last Name:SISK
Suffix:
Gender:F
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S LONGVIEW WAY APT 68
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1356
Mailing Address - Country:US
Mailing Address - Phone:503-888-3656
Mailing Address - Fax:
Practice Address - Street 1:10564 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2809
Practice Address - Country:US
Practice Address - Phone:503-888-3656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16-CRM-153175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR175T00000XMedicaid