Healthcare Provider Details

I. General information

NPI: 1528006921
Provider Name (Legal Business Name): JO ANNE NIELSEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14279 GLEN OAK RD
OREGON CITY OR
97045-8008
US

IV. Provider business mailing address

19069 S PIONEER CROSSING LN
ESTACADA OR
97023-9687
US

V. Phone/Fax

Practice location:
  • Phone: 503-657-7629
  • Fax: 503-557-8651
Mailing address:
  • Phone: 503-631-7087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD14362
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3323000
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerBCBS
# 2
Identifier128553
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: