Basic Information
| Provider Information | |||||||||
| NPI: | 1629115159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | MARY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6442 NE ALBERTA ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972183120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033352701 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 NE 7TH ST | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970305604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036615455 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 02/13/2008 | ||||||||
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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 | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 163WP0808X | OR | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.