Active NPI
Jordan Guy Probasco, D.C.
- Chiropractor
- Portland, OR
National Provider Identifier
1174901490
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Chiropractor
- License
- 5631
- Practice address
- 12661 SE Powell Blvd
Suite B
Portland, OR 97236-3400 - Phone
- (503) 801-8888
- NPI assigned
- May 7, 2015
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 5
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Chiropractor | 111N00000X | 5631 | OR | Primary |
| Pediatric Chiropractor | 111NP0017X | 5631 | OR | |
| Rehabilitation Chiropractor | 111NR0400X | 5631 | OR | |
| Occupational Health Chiropractor | 111NX0100X | 5631 | OR | |
| Orthopedic Chiropractor | 111NX0800X | 5631 | OR |
Addresses
Primary practice location
12661 SE Powell Blvd
Suite B
Portland, OR 97236-3400
Mailing address
1039 SE 78TH Ave
Portland, OR 97215-3006
Phone (509) 435-7124
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5631 | OR | MD | Occupational Health Chiropractor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1430956800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1430956800000",
"number": "1174901490",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1039 SE 78TH AVE",
"city": "PORTLAND",
"state": "OR",
"postal_code": "972153006",
"telephone_number": "509-435-7124"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12661 SE POWELL BLVD",
"address_2": "SUITE B",
"city": "PORTLAND",
"state": "OR",
"postal_code": "972363400",
"telephone_number": "503-801-8888"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PROBASCO",
"first_name": "JORDAN",
"middle_name": "GUY",
"name_prefix": "Dr.",
"credential": "D.C.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2015-05-07",
"last_updated": "2015-05-07",
"status": "A"
},
"taxonomies": [
{
"code": "111N00000X",
"taxonomy_group": "",
"desc": "Chiropractor",
"state": "OR",
"license": "5631",
"primary": true
},
{
"code": "111NP0017X",
"taxonomy_group": "",
"desc": "Chiropractor, Pediatric Chiropractor",
"state": "OR",
"license": "5631",
"primary": false
},
{
"code": "111NR0400X",
"taxonomy_group": "",
"desc": "Chiropractor, Rehabilitation",
"state": "OR",
"license": "5631",
"primary": false
},
{
"code": "111NX0100X",
"taxonomy_group": "",
"desc": "Chiropractor, Occupational Health",
"state": "OR",
"license": "5631",
"primary": false
},
{
"code": "111NX0800X",
"taxonomy_group": "",
"desc": "Chiropractor, Orthopedic",
"state": "OR",
"license": "5631",
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Portland, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 7, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.