Healthcare Provider Details

I. General information

NPI: 1174652473
Provider Name (Legal Business Name): SUZANNE MICHELE JAGGER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2007
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12525 NW CORNELL RD STE 204
PORTLAND OR
97229-5615
US

IV. Provider business mailing address

1925 NW 126TH PL
PORTLAND OR
97229-4627
US

V. Phone/Fax

Practice location:
  • Phone: 971-232-9232
  • Fax:
Mailing address:
  • Phone: 408-364-6103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number626041
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number201602463CRNA-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: