Healthcare Provider Details

I. General information

NPI: 1881677318
Provider Name (Legal Business Name): NATHALIE J. JACQMOTTE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 10/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6327 SE MILWAUKIE AVE
PORTLAND OR
97202-5418
US

IV. Provider business mailing address

PO BOX 22075
MILWAUKIE OR
97269-2075
US

V. Phone/Fax

Practice location:
  • Phone: 503-659-4988
  • Fax: 503-353-1297
Mailing address:
  • Phone: 503-659-4777
  • Fax: 503-652-5223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD24071
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: