Healthcare Provider Details

I. General information

NPI: 1952913923
Provider Name (Legal Business Name): JESSICA DENICE PANKEY CRM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SE HAILEY AVE
PENDLETON OR
97801-3073
US

IV. Provider business mailing address

PO BOX 882
PENDLETON OR
97801-0882
US

V. Phone/Fax

Practice location:
  • Phone: 541-663-4232
  • Fax: 541-429-8822
Mailing address:
  • Phone: 541-429-8800
  • Fax: 541-429-8822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number20-CRM-208
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: