Healthcare Provider Details

I. General information

NPI: 1306766415
Provider Name (Legal Business Name): JEREMY BUSACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 SE 14TH AVE
PORTLAND OR
97214-2549
US

IV. Provider business mailing address

2990 S MAGNOLIA DR
CORNELIUS OR
97113-7156
US

V. Phone/Fax

Practice location:
  • Phone: 208-703-6854
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: