Healthcare Provider Details

I. General information

NPI: 1144453143
Provider Name (Legal Business Name): JESSICA LEIGH VERSAGE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2009
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 S GARDEN WAY SUITE 220
EUGENE OR
97401-8176
US

IV. Provider business mailing address

PO BOX 1648
EUGENE OR
97440-1648
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-7007
  • Fax: 541-726-5028
Mailing address:
  • Phone: 541-686-7007
  • Fax: 541-684-3074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD155925
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier1144453143
Identifier TypeOTHER
Identifier State
Identifier IssuerNPI
# 2
Identifier500642003
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: