Healthcare Provider Details

I. General information

NPI: 1417264581
Provider Name (Legal Business Name): JARUSHA KUTZ PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1172 NE MORTON ST
PORTLAND OR
97211-4158
US

IV. Provider business mailing address

3519 NE 15TH AVE # 576
PORTLAND OR
97212-2356
US

V. Phone/Fax

Practice location:
  • Phone: 503-683-2109
  • Fax: 971-245-1736
Mailing address:
  • Phone: 503-683-2109
  • Fax: 971-245-1736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201050166NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: