Healthcare Provider Details

I. General information

NPI: 1093892556
Provider Name (Legal Business Name): JEANNE ELLEN HAISLIP OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 03/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 FOOTHILLS DR
NEWBERG OR
97132-6004
US

IV. Provider business mailing address

25117 SW PARKWAY AVE SUITE D
WILSONVILLE OR
97070-9697
US

V. Phone/Fax

Practice location:
  • Phone: 503-554-0767
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1006441
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: