Provider Demographics
NPI:1528460813
Name:CREVISTON, JACOB E (DNP, RN, PMHNP-BC)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:E
Last Name:CREVISTON
Suffix:
Gender:M
Credentials:DNP, RN, PMHNP-BC
Other - Prefix:DR
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:CREVISTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DNP, RN, PMHNP
Mailing Address - Street 1:745 NW HOYT ST UNIT 5482
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-8099
Mailing Address - Country:US
Mailing Address - Phone:971-213-5986
Mailing Address - Fax:503-405-8124
Practice Address - Street 1:1308 NW 20TH AVE STE 8
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1607
Practice Address - Country:US
Practice Address - Phone:971-213-5986
Practice Address - Fax:503-405-8124
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201405518NP-PP363LP0808X
OR200841169RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse