Basic Information
| Provider Information | |||||||||
| NPI: | 1497809164 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKINSON | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6704 SE 75TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972067248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034321458 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1700 NW CIVIC DR | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970303770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036668832 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 01/12/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | 2159 | OR | Y | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | 2159 | OR | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.