Basic Information
| Provider Information | |||||||||
| NPI: | 1144895012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRELL | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | PSS, THW, CRM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2995 RYAN DR SE STE 200 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973015157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033717701 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 182 SW ACADEMY ST | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973381996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036239289 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2021 | ||||||||
| LastUpdateDate: | 09/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | THW000003374 | OR | Y |
No ID Information.