Healthcare Provider Details

I. General information

NPI: 1306650619
Provider Name (Legal Business Name): JESSICA RELINA HUMPHREY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10315 NE TANASBOURNE DR STE 300
HILLSBORO OR
97124-7837
US

IV. Provider business mailing address

10315 NE TANASBOURNE DR STE 300
HILLSBORO OR
97124-7837
US

V. Phone/Fax

Practice location:
  • Phone: 503-531-1700
  • Fax:
Mailing address:
  • Phone: 503-531-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number120318
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: