Healthcare Provider Details

I. General information

NPI: 1720794589
Provider Name (Legal Business Name): EMMA WENDI JEGTVIG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 MARCOLA RD
SPRINGFIELD OR
97477-2594
US

IV. Provider business mailing address

85326 DILLEY LN
EUGENE OR
97405-9667
US

V. Phone/Fax

Practice location:
  • Phone: 541-747-4300
  • Fax: 541-747-0655
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number108118
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: