Provider Demographics
NPI:1659167724
Name:FIELDS, JUSTIN KERRY
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:KERRY
Last Name:FIELDS
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 1:6914 REDSTART RD
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-9244
Mailing Address - Country:US
Mailing Address - Phone:530-405-7237
Mailing Address - Fax:
Practice Address - Street 1:1824 VINE AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-3362
Practice Address - Country:US
Practice Address - Phone:530-405-7237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR112924175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist