Provider Demographics
NPI:1326802232
Name:ZACHEM CALDWELL, JESSICA LYNN
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:ZACHEM CALDWELL
Suffix:
Gender:F
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 4228
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4228
Mailing Address - Country:US
Mailing Address - Phone:541-316-6026
Mailing Address - Fax:541-323-3866
Practice Address - Street 1:375 NW BEAVER ST STE 101
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1802
Practice Address - Country:US
Practice Address - Phone:541-383-3005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORF01240682363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500833897Medicaid