Provider Demographics
NPI:1396436325
Name:OOTEN, JONATHAN PAUL
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PAUL
Last Name:OOTEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 13TH ST NE STE 304
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2202
Mailing Address - Country:US
Mailing Address - Phone:706-951-8625
Mailing Address - Fax:
Practice Address - Street 1:1233 EDGEWATER ST NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-4049
Practice Address - Country:US
Practice Address - Phone:503-378-7526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA216302363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program