Healthcare Provider Details

I. General information

NPI: 1750871802
Provider Name (Legal Business Name): JILLIAN GOLD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5329 NE MARTIN LUTHER KING BLVD
PORTLAND OR
97211-3237
US

IV. Provider business mailing address

619 NW 6TH AVE FL 5
PORTLAND OR
97209-3964
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-7468
  • Fax:
Mailing address:
  • Phone: 503-988-7468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD61031998
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD215329
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: