Basic Information
| Provider Information | |||||||||
| NPI: | 1760724090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7650 SW BEVELAND RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036013615 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19250 SW 65TH AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | TUALATIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970627707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036921242 | ||||||||
| FaxNumber: | 5036913615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD182960 | OR | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 500726543 | 05 | OR | MEDICAID |