Provider Demographics
NPI:1346069721
Name:CASIMIRO ORTIZ, JAQUELIN (CHW)
Entity type:Individual
Prefix:
First Name:JAQUELIN
Middle Name:
Last Name:CASIMIRO ORTIZ
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18633 SE STARK ST STE 401
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-5468
Mailing Address - Country:US
Mailing Address - Phone:503-489-1760
Mailing Address - Fax:503-489-1760
Practice Address - Street 1:18633 SE STARK ST
Practice Address - Street 2:STE 401
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5468
Practice Address - Country:US
Practice Address - Phone:503-489-1760
Practice Address - Fax:503-489-1763
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1841592110OtherWALLACE MEDICAL CONCERN