1629767041 NPI number — JENNIFER LEANN TIERNEY MW DANCEL

Table of content: JENNIFER LEANN TIERNEY MW DANCEL (NPI 1629767041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629767041 NPI number — JENNIFER LEANN TIERNEY MW DANCEL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DANCEL
Provider First Name:
JENNIFER
Provider Middle Name:
LEANN TIERNEY MW
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DANCEL
Provider Other First Name:
KAPU
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1629767041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14038 SE UPPER ALDERCREST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKIE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97267-1809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-264-1755
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 NE 20TH AVE STE 250
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:
97232-2282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-957-3391
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/02/2023

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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