Healthcare Provider Details

I. General information

NPI: 1700893674
Provider Name (Legal Business Name): JACQUELYN OUTCALT GROSHONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 MEDICAL LOOP RD SUITE 170
ROSEBURG OR
97471-8835
US

IV. Provider business mailing address

PO BOX 1700
ROSEBURG OR
97470-0414
US

V. Phone/Fax

Practice location:
  • Phone: 541-957-5437
  • Fax: 541-464-5441
Mailing address:
  • Phone: 541-957-5437
  • Fax: 541-464-5441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD18388
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: