Provider Demographics
NPI:1457334310
Name:JACKMAN, SIRI (NMNP-PP)
Entity type:Individual
Prefix:
First Name:SIRI
Middle Name:
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:NMNP-PP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 SW 4TH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-4516
Mailing Address - Country:US
Mailing Address - Phone:541-889-2229
Mailing Address - Fax:541-889-4378
Practice Address - Street 1:1219 SW 4TH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-4516
Practice Address - Country:US
Practice Address - Phone:541-889-2229
Practice Address - Fax:541-889-4378
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR077038713N5363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150513Medicaid