Provider Demographics
NPI:1114560802
Name:STAUBACH, JESSE C
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:C
Last Name:STAUBACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 802
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0148
Mailing Address - Country:US
Mailing Address - Phone:541-295-9240
Mailing Address - Fax:
Practice Address - Street 1:320 CENTRAL AVE STE 304
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2241
Practice Address - Country:US
Practice Address - Phone:541-366-7640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000003807175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist