Healthcare Provider Details

I. General information

NPI: 1013055664
Provider Name (Legal Business Name): KEIVAN A. JINNAH N.D., L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 SE MILWAUKIE AVE STE F
PORTLAND OR
97202-3835
US

IV. Provider business mailing address

3007 SE BELMONT ST
PORTLAND OR
97214-4026
US

V. Phone/Fax

Practice location:
  • Phone: 503-239-7341
  • Fax:
Mailing address:
  • Phone: 503-445-7115
  • Fax: 503-445-7116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00393
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number0972
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: