Basic Information
Provider Information | |||||||||
NPI: | 1063615672 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCALL | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | LYNN FILE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FILE | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3181 SW SAM JACKSON PARK ROAD | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972393011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034941303 | ||||||||
FaxNumber: | 5033468021 | ||||||||
Practice Location | |||||||||
Address1: | 3181 SW SAM JACKSON PARK ROAD | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 97239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034941303 | ||||||||
FaxNumber: | 5033468021 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2007 | ||||||||
LastUpdateDate: | 01/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 20A10054 | CA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | DO126209 | OR | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 1134146939 | 05 | OR |   | MEDICAID |