Basic Information
Provider Information | |||||||||
NPI: | 1356518302 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MALEY | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | CAROL | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | IMF | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BROWN | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | CAROL | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | IMF | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1483 POPLAR DR | ||||||||
Address2: | APT. 6 | ||||||||
City: | MEDFORD | ||||||||
State: | OR | ||||||||
PostalCode: | 975045286 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7602775921 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 695 MISTLETOE RD | ||||||||
Address2: | SUITE H | ||||||||
City: | ASHLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 975209552 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5414828906 | ||||||||
FaxNumber: | 5414826462 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/09/2008 | ||||||||
LastUpdateDate: | 05/22/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 56373 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.