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1528460813 NPI number — JACOB E. CREVISTON DNP, RN, PMHNP-BC

NPI Number: 1528460813
Health Care Provider/Practitioner: JACOB E. CREVISTON DNP, RN, PMHNP-BC

Information about “1528460813” NPI (JACOB E. CREVISTON DNP, RN, PMHNP-BC) exists in 1528460813 in HTML format HTML  |  1528460813 in plain Text format TXT  |  1528460813 in PDF (Portable Document Format) PDF  |  1528460813 in an XML format XML  formats.

NPI Number : 1528460813 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1528460813",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "CREVISTON",
    "FirstName": "JACOB",
    "MiddleName": "E.",
    "NamePrefix": "DR.",
    "NameSuffix": null,
    "Credential": "DNP, RN, PMHNP-BC",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "CREVISTON",
    "OtherFirstName": "JAKE",
    "OtherMiddleName": null,
    "OtherNamePrefix": "DR.",
    "OtherNameSuffix": null,
    "OtherCredential": "DNP, RN, PMHNP",
    "OtherLastNameTypeCode": "2",
    "FirstLineMailingAddress": "745 NW HOYT ST UNIT 5482",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "PORTLAND",
    "MailingAddressStateName": "OR",
    "MailingAddressPostalCode": "97208-8099",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "971-213-5986",
    "MailingAddressFaxNumber": "503-405-8124",
    "FirstLinePracticeLocationAddress": "1308 NW 20TH AVE STE 8",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "PORTLAND",
    "PracticeLocationAddressStateName": "OR",
    "PracticeLocationAddressPostalCode": "97209-1607",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "971-213-5986",
    "PracticeLocationAddressFaxNumber": "503-405-8124",
    "EnumerationDate": "09/18/2014",
    "LastUpdateDate": "09/20/2024",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "363LP0808X",
          "TaxonomyName": "Psychiatric/Mental Health Nurse Practitioner",
          "LicenseNumber": "201405518NP-PP",
          "LicenseNumberStateCode": "OR",
          "PrimaryTaxonomySwitch": "Y"
        },
        {
          "TaxonomyCode": "163W00000X",
          "TaxonomyName": "Registered Nurse",
          "LicenseNumber": "200841169RN",
          "LicenseNumberStateCode": "OR",
          "PrimaryTaxonomySwitch": "N"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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