Basic Information
| Provider Information | |||||||||
| NPI: | 1366989832 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDER | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10201 SE MAIN ST STE 10 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972162937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032552186 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10201 SE MAIN ST STE 10 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972162937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032552186 | ||||||||
| FaxNumber: | 5032552194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2017 | ||||||||
| LastUpdateDate: | 11/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | L7502 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | SWP.0001182 | CO | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.