Provider Demographics
NPI:1750703559
Name:LUCKMAN, JESSICA LYNN (WHNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:LUCKMAN
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:BELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:WHNP
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:541-732-7460
Mailing Address - Fax:541-732-7461
Practice Address - Street 1:940 ROYAL AVE
Practice Address - Street 2:STE 350
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6193
Practice Address - Country:US
Practice Address - Phone:541-732-7460
Practice Address - Fax:541-732-7461
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201400211NP-PP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500667248Medicaid
OR500667248Medicaid