MEDICARE: JESSIKA FATU

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	261QC1500X	Community Health Clinic/Center

General Provider Information

NPI Number	:	1366018343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSIKA FATU

Provider Business Mailing Address
First Line	:	6736 NE KILLINGSWORTH ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97218-3338
Country	:	US
Telephone Number	:	503-351-3955
Fax Number	:

Provider Business Practice Location Address
First Line	:	6736 NE KILLINGSWORTH ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97218-3338
Country	:	US
Telephone Number	:	503-351-3955
Fax Number	:

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

Provider Enumeration Date	:	06/01/2021
Last Update Date	:	06/01/2021

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Directions to “ JESSIKA FATU ” Practice Location

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