Provider Demographics
NPI:1720794589
Name:JEGTVIG, EMMA WENDI
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:WENDI
Last Name:JEGTVIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85326 DILLEY LN
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-9667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2280 MARCOLA RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-2594
Practice Address - Country:US
Practice Address - Phone:541-747-4300
Practice Address - Fax:541-747-0655
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR108118172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker