Basic Information
| Provider Information | |||||||||
| NPI: | 1144616665 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORP | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 SE 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032350131 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 SE 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032350131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2015 | ||||||||
| LastUpdateDate: | 01/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | R2910 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | 16-05-05 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | R2910 | 01 | OR | OREGON BOARD OF COUNSELORS, REGISTERED INTERN | OTHER |