Healthcare Provider Details

I. General information

NPI: 1801554092
Provider Name (Legal Business Name): JARROD S KUCHERAK MSN, APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2021
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12710 SE DIVISION ST
PORTLAND OR
97236-3134
US

IV. Provider business mailing address

12710 SE DIVISION ST
PORTLAND OR
97236-3134
US

V. Phone/Fax

Practice location:
  • Phone: 440-832-1873
  • Fax:
Mailing address:
  • Phone: 440-832-1873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10026960
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0030408
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: