Healthcare Provider Details

I. General information

NPI: 1952710352
Provider Name (Legal Business Name): JEANNINE DENIECE DEAVILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEANNINE DENIECE MARSHALL

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 S COAST HWY STE 1
SOUTH BEACH OR
97366-9667
US

IV. Provider business mailing address

36 SW NYE ST
NEWPORT OR
97365-3821
US

V. Phone/Fax

Practice location:
  • Phone: 541-574-5960
  • Fax: 541-265-0601
Mailing address:
  • Phone: 541-265-0581
  • Fax: 541-574-6252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: