Basic Information
| Provider Information | |||||||||
| NPI: | 1972519429 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'BOYLE-JORDAN | ||||||||
| FirstName: | BRIDGET | ||||||||
| MiddleName: | THERESA | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 574 | ||||||||
| Address2: | MAIL CODE CDRC | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972070574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034940429 | ||||||||
| FaxNumber: | 5034944447 | ||||||||
| Practice Location | |||||||||
| Address1: | 21900 WILLAMETTE DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | WEST LINN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970683284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036530631 | ||||||||
| FaxNumber: | 5036531464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 200541965RN | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 200550154NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 023299 | 05 | OR | MEDICAID |