Basic Information
| Provider Information | |||||||||
| NPI: | 1336485846 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROGUE FUNCTIONAL WELLNESS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 761 GOLF VIEW DR | ||||||||
| Address2: | STE C | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975049655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413264294 | ||||||||
| FaxNumber: | 8666299347 | ||||||||
| Practice Location | |||||||||
| Address1: | 761 GOLF VIEW DR | ||||||||
| Address2: | STE C | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975049655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413264294 | ||||||||
| FaxNumber: | 8666299347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2013 | ||||||||
| LastUpdateDate: | 09/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | JEX | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5413264294 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | FNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.