Basic Information
| Provider Information | |||||||||
| NPI: | 1457848574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLTTUM | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | KIMBERLEY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7650 SW BEVELAND ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038551620 | ||||||||
| FaxNumber: | 5038403299 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 NW 22ND AVE STE 520 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972102976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032744800 | ||||||||
| FaxNumber: | 5032744917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2018 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207V00000X | MD209450 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.