Provider Demographics
NPI:1912861303
Name:FEDESCO, JENNY
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:FEDESCO
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 1:12400 SE FREEMAN WAY
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4611
Mailing Address - Country:US
Mailing Address - Phone:503-353-6000
Mailing Address - Fax:
Practice Address - Street 1:3606 SE LAKE RD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6949
Practice Address - Country:US
Practice Address - Phone:503-353-5727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-12-11
Last Update Date:2025-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201803915RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse