Healthcare Provider Details

I. General information

NPI: 1154471928
Provider Name (Legal Business Name): JEANNIE LYNN RICHARDSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4590 SWEGLE RD NE
SALEM OR
97301-2012
US

IV. Provider business mailing address

4588 SWEGLE RD NE
SALEM OR
97301-2012
US

V. Phone/Fax

Practice location:
  • Phone: 503-371-6739
  • Fax: 503-763-2419
Mailing address:
  • Phone: 503-371-6739
  • Fax: 503-763-2419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: