Provider Demographics
NPI:1023103652
Name:REISS, JACOB ANDERSON (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ANDERSON
Last Name:REISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3325 N INTERSTATE AVE
Mailing Address - Street 2:KAISER PERMANENTE INTERSTATE MEDICAL OFFICE WEST
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1020
Mailing Address - Country:US
Mailing Address - Phone:503-813-2000
Mailing Address - Fax:
Practice Address - Street 1:3325 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1022
Practice Address - Country:US
Practice Address - Phone:503-331-6596
Practice Address - Fax:503-331-6320
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR MD08690207SG0201X
WAWA MD00013839207SG0201X
CAG21401207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)