MEDICARE: MRS. JAMIE KERSENBROCK BARBARA FNP-BC, RN, BSN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	201501756RN	OR
2	363LF0000X	Family Nurse Practitioner	201501757NP-PP	OR

General Provider Information

NPI Number	:	1134535180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JAMIE KERSENBROCK BARBARA FNP-BC, RN, BSN

Provider Business Mailing Address
First Line	:	1010 NE SKIDMORE ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97211-3476
Country	:	US
Telephone Number	:	541-206-2696
Fax Number	:

Provider Business Practice Location Address
First Line	:	5200 MEADOWS RD
Second Line	:	SUITE 250
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-3202
Country	:	US
Telephone Number	:	503-445-2200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2014
Last Update Date	:	02/01/2017

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