Basic Information
| Provider Information | |||||||||
| NPI: | 1447432190 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RENNA | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1793 13TH ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973022541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033628385 | ||||||||
| FaxNumber: | 5033628435 | ||||||||
| Practice Location | |||||||||
| Address1: | 1610 12TH ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973022821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413166575 | ||||||||
| FaxNumber: | 5412108913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2007 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA60133630 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA 153839 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 384377 | 05 | OR | MEDICAID |