Healthcare Provider Details

I. General information

NPI: 1063456200
Provider Name (Legal Business Name): JENNIFER L NYBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1742 W 10TH AVE
EUGENE OR
97402-3710
US

IV. Provider business mailing address

3645 SNOWBERRY RD
EUGENE OR
97403-3262
US

V. Phone/Fax

Practice location:
  • Phone: 541-343-8449
  • Fax:
Mailing address:
  • Phone: 541-908-2191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number27 3506
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier213426
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: