Basic Information
Provider Information | |||||||||
NPI: | 1366769523 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTS | ||||||||
FirstName: | JAMIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 676 NE NEGUS WAY | ||||||||
Address2: |   | ||||||||
City: | REDMOND | ||||||||
State: | OR | ||||||||
PostalCode: | 977568527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5415049577 | ||||||||
FaxNumber: | 5415042361 | ||||||||
Practice Location | |||||||||
Address1: | 676 NE NEGUS WAY | ||||||||
Address2: |   | ||||||||
City: | REDMOND | ||||||||
State: | OR | ||||||||
PostalCode: | 977568527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5415049577 | ||||||||
FaxNumber: | 5415042361 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2010 | ||||||||
LastUpdateDate: | 04/28/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA0400X | 092000466RN | OR | N |   | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | 163WP0000X | 092000466RN | OR | Y |   | Nursing Service Providers | Registered Nurse | Pain Management |
ID Information
ID | Type | State | Issuer | Description | 210831 | 05 | OR |   | MEDICAID |