Provider Demographics
NPI:1316249709
Name:JEANOTTE, SUSAN N (RN, CCM)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:N
Last Name:JEANOTTE
Suffix:
Gender:F
Credentials:RN, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 SE 67TH AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-6169
Mailing Address - Country:US
Mailing Address - Phone:503-348-7625
Mailing Address - Fax:503-626-2702
Practice Address - Street 1:7668 SW MOHAWK ST
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8119
Practice Address - Country:US
Practice Address - Phone:503-885-5117
Practice Address - Fax:866-350-1311
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000033099RN163W00000X
OR00042366163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management