Healthcare Provider Details

I. General information

NPI: 1629804059
Provider Name (Legal Business Name): JO ELLEN ZUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2955 N HWY 97
BEND OR
97703-7559
US

IV. Provider business mailing address

66900 SAGEBRUSH LN
BEND OR
97703-9292
US

V. Phone/Fax

Practice location:
  • Phone: 541-203-0474
  • Fax: 541-610-1692
Mailing address:
  • Phone: 541-788-8484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: