Provider Demographics
NPI:1124900915
Name:NUGENT, JESSIE
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:NUGENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6654 N FESSENDEN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-1812
Mailing Address - Country:US
Mailing Address - Phone:907-854-5023
Mailing Address - Fax:
Practice Address - Street 1:2031 SE BELMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2812
Practice Address - Country:US
Practice Address - Phone:907-854-5023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-23
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORBAP-E-10258400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist