Organization
YC SBHC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MICHAEL P JACZKO DO (MEDICAL DIRECTOR)
(503) 852-6960
Entity
Organization
Contact information
Practice address
120 LARCH PL, YAMHILL, OR 97148-2007
(503) 852-6960
Mailing address
PO BOX 544, YAMHILL, OR 97148-0544
Taxonomy
Speciality
Code
Description
License number
State
363LP2300X
Primary Care Nurse Practitioner
Primary
201250196NP
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1487647954
NPI
—
05
—
500652931
—
OR
Enumeration date
02/11/2016
Last updated
02/11/2016
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