Healthcare Provider Details

I. General information

NPI: 1063826212
Provider Name (Legal Business Name): JESSICA DAWN YACQUES APRN,FNP, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA DAWN BLAIR

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 MADISON AVE SW SUITE 209
CORVALLIS OR
97333-4757
US

IV. Provider business mailing address

257 SW MADISON AVE STE 209
CORVALLIS OR
97333-4757
US

V. Phone/Fax

Practice location:
  • Phone: 614-420-5093
  • Fax: 971-233-6398
Mailing address:
  • Phone: 971-368-1045
  • Fax: 971-233-6398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10043053
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10043053
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: