MEDICARE: DESIREE JEANNE ROOD PSS

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	175T00000X	Peer Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	THW000002909	OTHER	OR	OREGON HEALTH AUTHORITY

General Provider Information

NPI Number	:	1487114674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESIREE JEANNE ROOD PSS

Provider Business Mailing Address
First Line	:	1248 PENN ST SW
Second Line	:
City	:	ALBANY
State	:	OR
Zip	:	97321-2145
Country	:	US
Telephone Number	:	971-276-3608
Fax Number	:

Provider Business Practice Location Address
First Line	:	1248 PENN ST SW
Second Line	:
City	:	ALBANY
State	:	OR
Zip	:	97321-2145
Country	:	US
Telephone Number	:	971-276-3608
Fax Number	:

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

Provider Enumeration Date	:	03/22/2019
Last Update Date	:	03/22/2019

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