Provider Demographics
NPI:1992072789
Name:SANDERS, JENNIFER L (LDM, CPM)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:SANDERS
Suffix:
Gender:F
Credentials:LDM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4903 SE 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-4641
Mailing Address - Country:US
Mailing Address - Phone:503-467-8697
Mailing Address - Fax:
Practice Address - Street 1:4861 SE 64TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-4639
Practice Address - Country:US
Practice Address - Phone:503-467-8697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDEMLD10144711176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500648827Medicaid