Healthcare Provider Details

I. General information

NPI: 1770809303
Provider Name (Legal Business Name): AUDRA RACHELLE NORRIS-JACOB MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24850 SE STARK ST STE 200
GRESHAM OR
97030-8320
US

IV. Provider business mailing address

24850 SE STARK ST STE 200
GRESHAM OR
97030-8320
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-9444
  • Fax:
Mailing address:
  • Phone: 503-491-9444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD168646
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: