Basic Information
| Provider Information | |||||||||
| NPI: | 1508890179 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER-DAVIS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | W | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2240 SALAMO ROAD | ||||||||
| Address2: | 201 | ||||||||
| City: | WEST LINN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037237234 | ||||||||
| FaxNumber: | 5036504464 | ||||||||
| Practice Location | |||||||||
| Address1: | 22400 SALAMO RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | WEST LINN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970688269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037237234 | ||||||||
| FaxNumber: | 5036504464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 09/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD26751 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | MD26751 | OR | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | BM7833444 | 01 | DEA CERTIFICATE | OTHER | 240048 | 05 | OR | MEDICAID |