Provider Demographics
NPI:1700893674
Name:GROSHONG, JACQUELYN OUTCALT (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:OUTCALT
Last Name:GROSHONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1700
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0414
Mailing Address - Country:US
Mailing Address - Phone:541-957-5437
Mailing Address - Fax:541-464-5441
Practice Address - Street 1:201 MEDICAL LOOP RD
Practice Address - Street 2:SUITE 170
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8835
Practice Address - Country:US
Practice Address - Phone:541-957-5437
Practice Address - Fax:541-464-5441
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18388208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR070511Medicaid
F98769Medicare UPIN