Basic Information
| Provider Information | |||||||||
| NPI: | 1750373593 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MITCHELL | ||||||||
| FirstName: | JAYNE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 975 SE SANDY BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039632846 | ||||||||
| FaxNumber: | 5039639505 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 NE 99TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972209428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039633030 | ||||||||
| FaxNumber: | 5039633005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 12/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 086006006N3 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 292348 | 05 | OR | MEDICAID | 9645607 | 05 | WA | MEDICAID |