1164635561 NPI number — MS. JAN LINETTE POLSON L,AC., DIPL. AC.

Table of content: STACY ANN WASON-FAWVER NP (NPI 1194143347)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164635561 NPI number — MS. JAN LINETTE POLSON L,AC., DIPL. AC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLSON
Provider First Name:
JAN
Provider Middle Name:
LINETTE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
L,AC., DIPL. AC.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POLSON
Provider Other First Name:
JANN
Provider Other Middle Name:
LINETTE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
L.AC., DIPL. AC.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1164635561
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8221 SE ASPEN SUMMIT DR.
Provider Second Line Business Mailing Address:
# 11
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97266-9221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-481-5904
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6214 SE MILWAUKIE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-481-5904
Provider Business Practice Location Address Fax Number:
503-233-8995
Provider Enumeration Date:
05/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AC00982 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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