Healthcare Provider Details

I. General information

NPI: 1801272513
Provider Name (Legal Business Name): JEREMY BRODHEAD N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 SW CENTURY DR STE 201
BEND OR
97702-1338
US

IV. Provider business mailing address

339 SW CENTURY DR STE 201
BEND OR
97702-1338
US

V. Phone/Fax

Practice location:
  • Phone: 541-316-5693
  • Fax: 541-255-0947
Mailing address:
  • Phone: 541-316-5693
  • Fax: 541-255-0947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number201507653NP-PP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number200843322RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: