Healthcare Provider Details

I. General information

NPI: 1528625639
Provider Name (Legal Business Name): PACIFIC PRIMARY CARE AND INTEGRATIVE HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 05/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17200 NW CORRIDOR CT STE 110
BEAVERTON OR
97006-3295
US

IV. Provider business mailing address

728 MOLALLA AVE
OREGON CITY OR
97045-2799
US

V. Phone/Fax

Practice location:
  • Phone: 503-213-3800
  • Fax: 503-747-5345
Mailing address:
  • Phone: 503-487-3001
  • Fax: 503-656-9026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNA MICHELLE WILSON CRAIN
Title or Position: DIR. OF CLINICAL OUTCOMES
Credential: ND
Phone: 503-487-3001