Provider Demographics
NPI:1699701631
Name:LIETZKE, JENNIFER ANNE (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:LIETZKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6149
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-0149
Mailing Address - Country:US
Mailing Address - Phone:503-352-8657
Mailing Address - Fax:503-352-8658
Practice Address - Street 1:2935 SW CEDAR HILLS BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-1342
Practice Address - Country:US
Practice Address - Phone:503-352-6000
Practice Address - Fax:503-352-6080
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD28993207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500634215Medicaid