Healthcare Provider Details

I. General information

NPI: 1912154089
Provider Name (Legal Business Name): JACQUELINE D LEBRUN AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8495 CRATER LAKE HWY
WHITE CITY OR
97503-3011
US

IV. Provider business mailing address

2450 NE MARY ROSE PL STE 120
BEND OR
97701-7132
US

V. Phone/Fax

Practice location:
  • Phone: 541-830-7593
  • Fax:
Mailing address:
  • Phone: 541-382-6799
  • Fax: 541-312-7050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number20617
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number20617
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: