Healthcare Provider Details

I. General information

NPI: 1700615192
Provider Name (Legal Business Name): JACLYN MARIE WINFREE HOGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACLYN MARIE WINFREE

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 NW BETHANY BLVD STE 200
BEAVERTON OR
97006-5236
US

IV. Provider business mailing address

PO BOX 8459
PORTLAND OR
97207-8459
US

V. Phone/Fax

Practice location:
  • Phone: 503-741-2735
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10023286
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number10023286
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: