MEDICARE: MS. JEANNE ELLEN HAISLIP OT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	1006441	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	200072540A	OTHER	OK	DDS DHS
2	200072540B	OTHER	OK	NON-FED MED

General Provider Information

NPI Number	:	1093892556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JEANNE ELLEN HAISLIP OT

Provider Business Mailing Address
First Line	:	25117 SW PARKWAY AVE
Second Line	:	SUITE D
City	:	WILSONVILLE
State	:	OR
Zip	:	97070-9697
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	730 FOOTHILLS DR
Second Line	:
City	:	NEWBERG
State	:	OR
Zip	:	97132-6004
Country	:	US
Telephone Number	:	503-554-0767
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	03/28/2013

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