MEDICARE: JACOB TRAVIS WALDRON

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	390200000X	Student in an Organized Health Care Education/Training Program		OR

General Provider Information

NPI Number	:	1902765118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB TRAVIS WALDRON

Provider Business Mailing Address
First Line	:	18710 MIAMI FOLEY RD
Second Line	:
City	:	BAY CITY
State	:	OR
Zip	:	97107-9709
Country	:	US
Telephone Number	:	503-352-2020
Fax Number	:

Provider Business Practice Location Address
First Line	:	2043 COLLEGE WAY
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-1797
Country	:	US
Telephone Number	:	503-352-2020
Fax Number	:

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

Provider Enumeration Date	:	01/21/2026
Last Update Date	:	01/21/2026

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Directions to “ JACOB TRAVIS WALDRON ” Practice Location

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