Healthcare Provider Details

I. General information

NPI: 1962293472
Provider Name (Legal Business Name): OR WEIGHTLOSS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2025
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4655 SW GRIFFITH DR
BEAVERTON OR
97005-8728
US

IV. Provider business mailing address

4655 SW GRIFFITH DR
BEAVERTON OR
97005-8728
US

V. Phone/Fax

Practice location:
  • Phone: 917-488-6875
  • Fax:
Mailing address:
  • Phone: 917-488-6875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JILL ANGELA WARD
Title or Position: PHYSICIAN
Credential: MD
Phone: 904-535-4815