Basic Information
| Provider Information | |||||||||
| NPI: | 1033414438 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLINGTON | ||||||||
| FirstName: | JEFFREY | ||||||||
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| Credential: | MSW, LCSW, CADC-I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 SE 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141809 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 727 NE 24TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032289229 | ||||||||
| FaxNumber: | 5032289558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2011 | ||||||||
| LastUpdateDate: | 01/18/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.