Healthcare Provider Details

I. General information

NPI: 1619794708
Provider Name (Legal Business Name): EMMETT JUBILEE PENNINGTON-GUTHRIE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2024
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 NE 162ND AVE
PORTLAND OR
97230-5760
US

IV. Provider business mailing address

360 LESLIE ST SE
SALEM OR
97301-3504
US

V. Phone/Fax

Practice location:
  • Phone: 503-408-4705
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number10032133
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: