Basic Information
| Provider Information | |||||||||
| NPI: | 1205911153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | NOELLE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2052 SE HAWTHORNE BLVD | ||||||||
| Address2: | APT. #102 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972143857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038048434 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3710 SW US VETERANS HOSPITAL RD | ||||||||
| Address2: | MAIL CODE P3MHDC | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972392964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032208262 | ||||||||
| FaxNumber: | 5032203499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.