Provider Demographics
NPI:1699300095
Name:SCHUMACHER, JUSTIN NEAL (PRC, PWS, CRM, PSS)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:NEAL
Last Name:SCHUMACHER
Suffix:
Gender:M
Credentials:PRC, PWS, CRM, PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11935 SE 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-6819
Mailing Address - Country:US
Mailing Address - Phone:260-446-1031
Mailing Address - Fax:
Practice Address - Street 1:173 NE 102ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4169
Practice Address - Country:US
Practice Address - Phone:503-906-9995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19-PRC-16175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR19-PRC-16OtherMHACBO
ORTHW000003153OtherOREGON HEALTH AUTHORITY