Healthcare Provider Details

I. General information

NPI: 1093587933
Provider Name (Legal Business Name): JACQUE COBB FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date: 04/30/2026
Reactivation Date: 07/16/2026

III. Provider practice location address

2801 ST ANTHONY WAY
PENDLETON OR
97801-3800
US

IV. Provider business mailing address

2801 ST ANTHONY WAY
PENDLETON OR
97801-3800
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-5121
  • Fax: 541-278-4579
Mailing address:
  • Phone: 541-276-5121
  • Fax: 541-278-4579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10063313
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number200340354
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: