Provider Demographics
NPI:1003272477
Name:JUSTESEN, DIONNE R
Entity Type:Individual
Prefix:
First Name:DIONNE
Middle Name:R
Last Name:JUSTESEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 WEBBER ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3749
Mailing Address - Country:US
Mailing Address - Phone:541-296-5452
Mailing Address - Fax:541-858-8167
Practice Address - Street 1:1060 WEBBER ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3749
Practice Address - Country:US
Practice Address - Phone:541-296-5452
Practice Address - Fax:541-298-1917
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2023-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1003272477101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1003272477Medicaid