Provider Demographics
NPI:1366769523
Name:ROBERTS, JAMIE (RN)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 NE NEGUS WAY
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-8527
Mailing Address - Country:US
Mailing Address - Phone:541-504-9577
Mailing Address - Fax:541-504-2361
Practice Address - Street 1:676 NE NEGUS WAY
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-8527
Practice Address - Country:US
Practice Address - Phone:541-504-9577
Practice Address - Fax:541-504-2361
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR092000466RN163WA0400X, 163WP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0000XNursing Service ProvidersRegistered NursePain Management
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210831Medicaid