Healthcare Provider Details

I. General information

NPI: 1003361858
Provider Name (Legal Business Name): JEFFERY WISE PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2016
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 SW MORRISON ST STE 730
PORTLAND OR
97205-2226
US

IV. Provider business mailing address

1750 NE VISTA AVE
GRESHAM OR
97030-4160
US

V. Phone/Fax

Practice location:
  • Phone: 971-354-9242
  • Fax:
Mailing address:
  • Phone: 503-781-5814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number01606596NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: