Basic Information
| Provider Information | |||||||||
| NPI: | 1558024687 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JERABEK | ||||||||
| FirstName: | CHARLES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11876 LITTLE CREEK LN | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322237101 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10810 SE SUNNYSIDE RD | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970159787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038132000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2021 | ||||||||
| LastUpdateDate: | 10/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 242T00000X | Y | Technologists, Technicians & Other Technical Service Providers | Perfusionist |
No ID Information.