Provider Demographics
NPI:1144685140
Name:MERRELL, JONATHAN DAVID (RN)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:MERRELL
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 NW NORTHRUP ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2790
Mailing Address - Country:US
Mailing Address - Phone:505-414-5550
Mailing Address - Fax:
Practice Address - Street 1:1414 NW NORTHRUP ST STE 8000
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2790
Practice Address - Country:US
Practice Address - Phone:503-414-5550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-18
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK67049163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse