Provider Demographics
NPI:1740253103
Name:HUMPHREY, JEFFREY S (DO)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:S
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SE UGLOW AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-2645
Mailing Address - Country:US
Mailing Address - Phone:503-623-8376
Mailing Address - Fax:503-623-5293
Practice Address - Street 1:1000 SE UGLOW AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-2645
Practice Address - Country:US
Practice Address - Phone:503-623-8376
Practice Address - Fax:503-623-5293
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO15134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1164780060OtherLOCATION NPI
OR149096Medicaid
OR01WCGWZCMedicare ID - Type Unspecified
OR149096Medicaid