Provider Demographics
NPI:1740062991
Name:VANDOR, JESSIE LYNNE (PA)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:LYNNE
Last Name:VANDOR
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 S BOND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4501
Mailing Address - Country:US
Mailing Address - Phone:503-494-4373
Mailing Address - Fax:503-418-4189
Practice Address - Street 1:3303 S BOND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-4373
Practice Address - Fax:503-418-4189
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-20
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA223585363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant