Basic Information
| Provider Information | |||||||||
| NPI: | 1770784274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENNINGS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | CADC II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2425 SW 171ST PL | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970064300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153094500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2415 SE 43RD AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972061600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032309654 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 05/31/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 11-R-10 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.