Healthcare Provider Details

I. General information

NPI: 1124900915
Provider Name (Legal Business Name): JESSIE NUGENT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2031 SE BELMONT ST
PORTLAND OR
97214-2812
US

IV. Provider business mailing address

2031 SE BELMONT ST
PORTLAND OR
97214-2812
US

V. Phone/Fax

Practice location:
  • Phone: 907-854-5023
  • Fax:
Mailing address:
  • Phone: 907-854-5023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberBAP-E-10258400
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: