Healthcare Provider Details

I. General information

NPI: 1356006233
Provider Name (Legal Business Name): JESSICA BLISS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2021
Last Update Date: 11/04/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SANTIAM MEMORIAL HOSPITAL 1410 N 10TH AVE
STAYTON OR
97383
US

IV. Provider business mailing address

1435 NW GREENWOOD PL
CORVALLIS OR
97330-1827
US

V. Phone/Fax

Practice location:
  • Phone: 503-769-2175
  • Fax:
Mailing address:
  • Phone: 541-231-2671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: