Provider Demographics
NPI:1043362221
Name:GARDNER, JEFF J (HAS)
Entity type:Individual
Prefix:MR
First Name:JEFF
Middle Name:J
Last Name:GARDNER
Suffix:
Gender:M
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 N COAST HWY STE D
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-2499
Mailing Address - Country:US
Mailing Address - Phone:541-265-6273
Mailing Address - Fax:
Practice Address - Street 1:1217 N COAST HWY STE D
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-2499
Practice Address - Country:US
Practice Address - Phone:541-265-6273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332S00000X
OR404279237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022742Medicaid
OR275249Medicaid