1740542919 NPI number — MRS. JESSICA D BENEDICT WHCNP

Table of content: MRS. JESSICA D BENEDICT WHCNP (NPI 1740542919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740542919 NPI number — MRS. JESSICA D BENEDICT WHCNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENEDICT
Provider First Name:
JESSICA
Provider Middle Name:
D
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
WHCNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TOWNSEND
Provider Other First Name:
JESSICA
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
WHCNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1740542919
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7650 SW BEVELAND RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97223-8692
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-734-3700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9701 SW BARNES RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97225-6772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-734-3700
Provider Business Practice Location Address Fax Number:
503-473-8462
Provider Enumeration Date:
06/13/2012

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: 363LW0102X , with the licence number:  201250073NP , 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)

  • Identifier: 500645846 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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