Healthcare Provider Details

I. General information

NPI: 1740741628
Provider Name (Legal Business Name): JENNA GORBATKIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 N GANTENBEIN AVE
PORTLAND OR
97227-1623
US

IV. Provider business mailing address

101 SW MAIN ST STE 940
PORTLAND OR
97204-3216
US

V. Phone/Fax

Practice location:
  • Phone: 503-276-6500
  • Fax:
Mailing address:
  • Phone: 503-464-9034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number91625
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: