Basic Information
| Provider Information | |||||||||
| NPI: | 1578518080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROVOST | ||||||||
| FirstName: | JEAN-CLAUDE | ||||||||
| MiddleName: | KLEBER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5100 S MACADAM AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712025500 | ||||||||
| FaxNumber: | 9712025555 | ||||||||
| Practice Location | |||||||||
| Address1: | 5100 S MACADAM AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712025500 | ||||||||
| FaxNumber: | 9712025555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 200350102NP FNP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 022717 | 05 | OR | MEDICAID | 067593030 | 01 | BLUE CROSS/BLUE SHIELD | OTHER |