Healthcare Provider Details

I. General information

NPI: 1770306672
Provider Name (Legal Business Name): JEMIMAH MANZANO BROOKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2024
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 N OAK HOLLOW DR
NEWBERG OR
97132-7475
US

IV. Provider business mailing address

619 N OAK HOLLOW DR
NEWBERG OR
97132-7475
US

V. Phone/Fax

Practice location:
  • Phone: 971-227-0028
  • Fax:
Mailing address:
  • Phone: 971-227-0028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number201607880RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: