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NPI Code Detail

MEDICARE: MR. JESSIE JEROME ISAAC MST, RC

MEDICARE: MR. JESSIE JEROME ISAAC MST, RC
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
1372600000XAdult Companion

General Provider Information

NPI Number : 1477691889
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JESSIE JEROME ISAAC MST, RC
Provider Business Mailing Address
First Line : 3608 SE 40TH AVE APT 3
Second Line :
City : PORTLAND
State : OR
Zip : 97202-1769
Country : US
Telephone Number : 503-493-9723
Fax Number :
Provider Business Practice Location Address
First Line : 7511 SE HENRY ST
Second Line :
City : PORTLAND
State : OR
Zip : 97206-6445
Country : US
Telephone Number : 503-771-6061
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/01/2007
Last Update Date : 07/08/2007

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