Provider Demographics
NPI:1487940318
Name:CARLSON, JESSICA R (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94220 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-7756
Mailing Address - Country:US
Mailing Address - Phone:541-247-3000
Mailing Address - Fax:541-247-3104
Practice Address - Street 1:94220 4TH ST
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-7756
Practice Address - Country:US
Practice Address - Phone:541-247-3910
Practice Address - Fax:541-247-3109
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD176604208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1487696985OtherCURRY GENERAL HOSPITAL NPI
OR500706467Medicaid
OR930937095OtherCURRY HEALTH DISTRICT TAX I.D.
ORR0000ZGBDGOtherCURRY HEALTH DISTRICT MEDICARE
OR119263OtherCURRY HEALTH DISTRICT MEDICAID