Provider Demographics
NPI:1215625066
Name:BRUCKER, SHELLEY ANNE (PMHNP)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:ANNE
Last Name:BRUCKER
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:ANNE
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:8900 SW SWEEK DR APT 1321
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 CENTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2682
Practice Address - Country:US
Practice Address - Phone:503-947-8109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR100076862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry