Provider Demographics
NPI:1336271147
Name:GALLARDO, JENNIFER S (CPM)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:S
Last Name:GALLARDO
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19255 SW 65TH AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9717
Mailing Address - Country:US
Mailing Address - Phone:503-885-0228
Mailing Address - Fax:
Practice Address - Street 1:19255 SW 65TH AVE STE 220
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9717
Practice Address - Country:US
Practice Address - Phone:503-885-0228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1000044176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210397Medicaid