Healthcare Provider Details

I. General information

NPI: 1023103652
Provider Name (Legal Business Name): JACOB ANDERSON REISS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3325 N INTERSTATE AVE
PORTLAND OR
97227-1022
US

IV. Provider business mailing address

3325 N INTERSTATE AVE KAISER PERMANENTE INTERSTATE MEDICAL OFFICE WEST
PORTLAND OR
97227-1020
US

V. Phone/Fax

Practice location:
  • Phone: 503-331-6596
  • Fax: 503-331-6320
Mailing address:
  • Phone: 503-813-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberOR MD08690
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberWA MD00013839
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberG21401
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: