Healthcare Provider Details

I. General information

NPI: 1750344826
Provider Name (Legal Business Name): JONATHAN GLENN HUWE MS, ATCR
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 SW HALL, RM 143A
PORTLAND OR
97201
US

IV. Provider business mailing address

14129 SE WOODWARD ST
PORTLAND OR
97236-2639
US

V. Phone/Fax

Practice location:
  • Phone: 503-725-4073
  • Fax: 503-725-5641
Mailing address:
  • Phone: 503-407-7206
  • Fax: 503-725-5641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-AT-808246
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: