Healthcare Provider Details

I. General information

NPI: 1255052494
Provider Name (Legal Business Name): JACQUELINE BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NE 8TH ST STE 300
GRESHAM OR
97030-7318
US

IV. Provider business mailing address

600 NE 8TH ST STE 300
GRESHAM OR
97030-7318
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-3633
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number390200000X
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: