Healthcare Provider Details

I. General information

NPI: 1619881430
Provider Name (Legal Business Name): BREAH JANICE ETHERLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 NE BROADWAY STE 200
PORTLAND OR
97213-1425
US

IV. Provider business mailing address

4425 NE BROADWAY STE 200
PORTLAND OR
97213-1425
US

V. Phone/Fax

Practice location:
  • Phone: 503-258-4555
  • Fax: 971-351-9144
Mailing address:
  • Phone: 503-258-4555
  • Fax: 971-351-9144

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 StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: