Provider Demographics
NPI:1689569642
Name:FAN, JAIME GWEN
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:GWEN
Last Name:FAN
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 1:11380 HOWLAND CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-5857
Mailing Address - Country:US
Mailing Address - Phone:407-409-0101
Mailing Address - Fax:
Practice Address - Street 1:500 NE MULTNOMAH ST STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2031
Practice Address - Country:US
Practice Address - Phone:503-813-3860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program