Healthcare Provider Details

I. General information

NPI: 1932017522
Provider Name (Legal Business Name): JAMIE NOVA CLARK PWS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 SE LAFAYETTE ST STE 100
PORTLAND OR
97202-3802
US

IV. Provider business mailing address

1219 SE LAFAYETTE ST STE 100
PORTLAND OR
97202-3802
US

V. Phone/Fax

Practice location:
  • Phone: 503-765-5733
  • Fax: 971-244-8583
Mailing address:
  • Phone: 503-765-5733
  • Fax: 971-244-8583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number118189
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: