Healthcare Provider Details

I. General information

NPI: 1376217042
Provider Name (Legal Business Name): JESSICA CHRISTINE VEGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

832 ELM ST SW STE 101
ALBANY OR
97321-2062
US

IV. Provider business mailing address

PO BOX 1189
CORVALLIS OR
97339-1189
US

V. Phone/Fax

Practice location:
  • Phone: 541-812-5820
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA211403
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: