Provider Demographics
NPI:1801847355
Name:LYCETTE, JENNIFER (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:LYCETTE
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 3397
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3397
Mailing Address - Country:US
Mailing Address - Phone:503-717-7443
Mailing Address - Fax:971-712-2199
Practice Address - Street 1:725 S WAHANNA RD STE 100
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138-7735
Practice Address - Country:US
Practice Address - Phone:503-717-7650
Practice Address - Fax:971-712-2199
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00045720207R00000X
ORMD24559207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine