Healthcare Provider Details

I. General information

NPI: 1487254751
Provider Name (Legal Business Name): JULIANNA GENTRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51340 HIGHWAY 97
LA PINE OR
97739-9871
US

IV. Provider business mailing address

800 NE YUCCA AVE
REDMOND OR
97756-8784
US

V. Phone/Fax

Practice location:
  • Phone: 541-322-7500
  • Fax:
Mailing address:
  • Phone: 541-854-0226
  • Fax: 541-322-7565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC9127
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: