Basic Information
| Provider Information | |||||||||
| NPI: | 1376962068 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | THIESSEN | ||||||||
| FirstName: | JACLYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | OREGON HEALTH AND SCIENCE UNIVERSITY | ||||||||
| Address2: | 3181 SAM JACKSON PARK RD. L340 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034949000 | ||||||||
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| Practice Location | |||||||||
| Address1: | OREGON HEALTH AND SCIENCE UNIVERSITY | ||||||||
| Address2: | 3181 SAM JACKSON PK RD., L340 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034949000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2014 | ||||||||
| LastUpdateDate: | 05/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085D0003X | MD198169 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | MD198169 | OR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.