| Contacts | Authorizing Official | Update | Group Change Request | Green, Jenna
Community Health Center Interim Executive Director
Multnomah County
5039886734 | Powers, Debbie
Interim Health Center Chief Operating Officer
Multnomah County
5039886742 | 4/29/2025 6:56 AM |
| Details | Last Recertification Date | Update | Recertification | 2/7/2024 1:32:08 PM | 2/10/2025 12:58:30 PM | 2/10/2025 12:58 PM |
| Contacts | Authorizing Official | Update | Group Change Request | Perry, Jeff
Finance Officer
Multnomah County
5036796544 | Green, Jenna
Community Health Center Interim Executive Director
Multnomah County
5039886734 | 4/12/2024 2:54 PM |
| Details | Last Recertification Date | Update | Recertification | 2/23/2023 1:16:22 PM | 2/7/2024 1:32:08 PM | 2/7/2024 1:32 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Recertification | | False | 2/23/2023 1:16 PM |
| Medicaid Billing | Medicaid: Number | Insert | Recertification | | 123620 | 2/23/2023 1:16 PM |
| Medicaid Billing | Medicaid: State | Insert | Recertification | | OR | 2/23/2023 1:16 PM |
| Contacts | Primary Contact | Update | Recertification | Espinoza Zavala, Rosalio
Pharmacy Program Analyst
Multnomah County
5039888852 | Hollensteiner, Astrid
Pharmacy Program Analyst
Multnomah County
5039888850 | 2/23/2023 1:16 PM |
| Details | Last Recertification Date | Update | Recertification | 1/31/2022 1:38:03 PM | 2/23/2023 1:16:22 PM | 2/23/2023 1:16 PM |
| Details | Last Recertification Date | Update | Recertification | 2/22/2021 3:11:07 PM | 1/31/2022 1:38:03 PM | 1/31/2022 1:38 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Lewis, Mark
Administrator
Multnomah County
5039887462 | Perry, Jeff
Finance Officer
Multnomah County
5036796544 | 3/15/2021 12:27 PM |
| Medicaid Billing | NPI: State | Update | Recertification | | OR | 2/22/2021 3:11 PM |
| Details | Last Recertification Date | Update | Recertification | 2/3/2020 11:05:40 AM | 2/22/2021 3:11:07 PM | 2/22/2021 3:11 PM |
| Addresses | Shipping Address | Insert | Recertification | | SOUTHEAST HEALTH CENTER PHARMACY
3653 SE 34TH AVE
PORTLAND, OR 97202-3034 | 2/3/2020 11:05 AM |
| Addresses | Billing Address | Update | Recertification | David Douglas SBHC
619 NW 6th Ave.
Ste. 500
Portland, OR 97209 | DAVID DOUGLAS HIGH SCHOOL STUDENT HEALTH CENTER
619 NW 6th Ave.
5th Floor
Portland, OR 97209 | 2/3/2020 11:05 AM |
| Details | Last Recertification Date | Update | Recertification | 2/6/2019 5:37:01 PM | 2/3/2020 11:05:40 AM | 2/3/2020 11:05 AM |
| Details | Entity Name | Update | Recertification | MULTNOMAH, COUNTY OF | MULTNOMAH COUNTY | 2/3/2020 11:05 AM |
| Contacts | Primary Contact | Update | Change Request | GADDIS, CAMMY
Finance Specialist
Multnomah County
5039887468 | Espinoza Zavala, Rosalio
Pharmacy Program Analyst
Multnomah County
5039888852 | 9/13/2019 6:37 AM |
| Addresses | Billing Address | Update | Change Request | David Douglas SBHC
421 SW Oak St.
Ste. 210
Portland, OR 97204 | David Douglas SBHC
619 NW 6th Ave.
Ste. 500
Portland, OR 97209 | 3/15/2019 6:12 PM |
| Details | Last Recertification Date | Update | Recertification | 2/12/2018 1:32:38 PM | 2/6/2019 5:37:01 PM | 2/6/2019 5:37 PM |
| Details | Last Recertification Date | Update | Recertification | 1/30/2017 12:00:00 AM | 2/12/2018 1:32:38 PM | 2/12/2018 1:32 PM |
| Details | Entity Subname | Update | Change Request | David Douglas High School-Based Health Center | DAVID DOUGLAS HIGH SCHOOL STUDENT HEALTH CENTER | 12/1/2017 7:15 AM |
| Contacts | Authorizing Official | Insert | Change Request | | Lewis, Mark
Administrator
Multnomah County
5039887462 | 10/10/2017 10:27 AM |
| Details | Is Authorizing Official EHB Data | Update | Change Request | False | | 10/10/2017 10:27 AM |
| Contacts | Primary Contact | Update | Profile Change Request | GADDIS, CAMMY
Finance Specialist
5039887468 | GADDIS, CAMMY
Finance Specialist
Multnomah County
5039887468 | 9/23/2017 10:00 AM |
| Contacts | Signed By | Insert | | | LEAR, WENDY
Administrator
5039887511 | 8/9/2017 3:51 PM |
| Contacts | Primary Contact | Insert | | | GADDIS, CAMMY
Finance Specialist
5039887468 | 8/9/2017 3:51 PM |
| Addresses | Main Address | Insert | | |
1034 SE 130th Ave
Portland, OR 97233-1616 | 1/30/2017 3:10 PM |
| Details | Last Recertification Date | Update | | | 1/30/2017 12:00:00 AM | 1/30/2017 3:10 PM |
| Addresses | Billing Address | Insert | | | David Douglas SBHC
421 SW Oak St.
Ste. 210
Portland, OR 97204 | 4/8/2016 3:53 PM |
| Dates | Participating Approval Date | Update | | | 4/8/2016 12:00:00 AM | 4/8/2016 3:53 PM |
| Details | State | Update | | Pending | Active | 4/8/2016 3:53 PM |
| Dates | Start Date | Update | | | 7/1/2016 12:00:00 AM | 4/8/2016 3:53 PM |
| Details | 340B ID | Update | | ONLINE_REG_58920 | CH10112AL | 4/6/2016 1:55 PM |
| Details | 340B ID | Update | | ONLINE_REG | ONLINE_REG_58920 | 4/4/2016 4:33 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/4/2016 4:33 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 022959 | 4/4/2016 4:33 PM |
| Medicaid Billing | Medicaid: State | Insert | | | OR | 4/4/2016 4:33 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/4/2016 4:33 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 096511 | 4/4/2016 4:33 PM |
| Medicaid Billing | Medicaid: State | Insert | | | OR | 4/4/2016 4:33 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1063725141 | 4/4/2016 4:33 PM |
| Details | Last Recertification Date | Insert | | | | 4/4/2016 4:33 PM |
| Details | Grant Number | Insert | | | H80CS00149 | 4/4/2016 4:33 PM |
| Details | 340B ID | Insert | | | ONLINE_REG | 4/4/2016 4:33 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | False | 4/4/2016 4:33 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/4/2016 4:33 PM |
| Details | Medicare Provider Number | Insert | | | | 4/4/2016 4:33 PM |
| Details | Entity Name | Insert | | | MULTNOMAH, COUNTY OF | 4/4/2016 4:33 PM |
| Details | Program Code | Insert | | | CH | 4/4/2016 4:33 PM |
| Details | Entity Subname | Insert | | | David Douglas High School-Based Health Center | 4/4/2016 4:33 PM |
| Dates | Participating Approval Date | Insert | | | | 4/4/2016 4:33 PM |
| Details | State | Insert | | | Pending | 4/4/2016 4:33 PM |
| Dates | Registration Date | Insert | | | 4/4/2016 12:00:00 AM | 4/4/2016 4:33 PM |
| Dates | Signed By Date | Insert | | | 4/4/2016 12:00:00 AM | 4/4/2016 4:33 PM |
| Dates | Start Date | Insert | | | | 4/4/2016 4:33 PM |
| Terminations | Termination Comments | Insert | | | | 4/4/2016 4:33 PM |
| Terminations | Termination Date | Insert | | | | 4/4/2016 4:33 PM |
| Terminations | Termination Effective Date | Insert | | | | 4/4/2016 4:33 PM |
| Terminations | Termination Reason | Insert | | | | 4/4/2016 4:33 PM |