Jaclyn Renee Derosso, AUD.

Primary specialty

AudiologistTaxonomy code 231H00000X

License

30928 Issued in OR

Practice address

18040 Sherman Way
Reseda, CA 91335-4631

Phone

(503) 997-4669

NPI assigned

Apr 4, 2019

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Jaclyn Renee Paulson Former name

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

Interoperability endpoints

• Direct secure messaging: jderosso1073381@oc.providencedirect.org

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1554336000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1602547200000",
    "number": "1184186447",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5309 SW MULTNOMAH BLVD",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972193345",
            "telephone_number": "541-979-2344"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "18040 SHERMAN WAY",
            "city": "RESEDA",
            "state": "CA",
            "postal_code": "913354631",
            "telephone_number": "503-997-4669"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DEROSSO",
        "first_name": "JACLYN",
        "middle_name": "RENEE",
        "name_prefix": "Dr.",
        "credential": "AUD.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-04-04",
        "last_updated": "2020-10-13",
        "certification_date": "2020-10-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "231H00000X",
            "taxonomy_group": "",
            "desc": "Audiologist",
            "state": "OR",
            "license": "30928",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "jderosso1073381@oc.providencedirect.org",
            "affiliation": "N",
            "address_1": "310 N Villa Rd Ste 106",
            "city": "Newberg",
            "state": "OR",
            "country_code": "US",
            "postal_code": "971321886",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "first_name": "JACLYN",
            "last_name": "PAULSON",
            "middle_name": "RENEE",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

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• Audiologist in Reseda, CA
• Providers in Reseda, CA by specialty
• Audiologist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 13, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.