Healthcare Provider Details

I. General information

NPI: 1447375167
Provider Name (Legal Business Name): JACQUELINE A THORESON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2958 SE 27TH CT
GRESHAM OR
97080-6293
US

IV. Provider business mailing address

2958 SE 27TH CT
GRESHAM OR
97080-6293
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-1043
  • Fax: 503-667-1043
Mailing address:
  • Phone: 503-667-1043
  • Fax: 503-667-1043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: