Provider Demographics
NPI:1174604359
Name:HERBERT, JEFFERY KOLK (PA)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:KOLK
Last Name:HERBERT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4334
Mailing Address - Country:US
Mailing Address - Phone:541-282-6685
Mailing Address - Fax:541-282-6686
Practice Address - Street 1:520 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 300
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4334
Practice Address - Country:US
Practice Address - Phone:541-282-6685
Practice Address - Fax:541-282-6686
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00572363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR064456Medicaid
OR4898008OtherBLUE CROSS
OR064456Medicaid
ORS53840Medicare UPIN