Provider Demographics
NPI:1174720221
Name:JAMES, JESICA (CPM, LDM)
Entity type:Individual
Prefix:MISS
First Name:JESICA
Middle Name:
Last Name:JAMES
Suffix:
Gender:F
Credentials:CPM, LDM
Other - Prefix:MS
Other - First Name:JESICA
Other - Middle Name:
Other - Last Name:DOLIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CPM, LDM
Mailing Address - Street 1:4903 SE 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-4641
Mailing Address - Country:US
Mailing Address - Phone:503-702-5392
Mailing Address - Fax:
Practice Address - Street 1:19255 SW 65TH AVE STE 220
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9717
Practice Address - Country:US
Practice Address - Phone:503-885-0228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1004154176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278230Medicaid