MEDICARE: DR. PAUL GEORGE JENDRE D.O.

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	207Q00000X	Family Medicine Physician	3854	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3854	OTHER	AZ	STATE LICENSE #

General Provider Information

NPI Number	:	1841299393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL GEORGE JENDRE D.O.

Provider Business Mailing Address
First Line	:	PO BOX 3158
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97208-3158
Country	:	US
Telephone Number	:	541-535-1274
Fax Number	:	541-535-6973

Provider Business Practice Location Address
First Line	:	205 FERN VALLEY RD STE A
Second Line	:
City	:	PHOENIX
State	:	OR
Zip	:	97535-9100
Country	:	US
Telephone Number	:	541-535-1274
Fax Number	:	541-535-6973

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

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	03/07/2023

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