Provider Demographics
NPI:1013546217
Name:LIDDELL, JEFF LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:LYNN
Last Name:LIDDELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:JEFF
Other - Middle Name:LYNN
Other - Last Name:LIDDELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:JEFF LIDDELL, LCSW
Mailing Address - Street 1:1803 N SIMPSON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-4658
Mailing Address - Country:US
Mailing Address - Phone:503-310-7591
Mailing Address - Fax:
Practice Address - Street 1:1803 N SIMPSON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-4658
Practice Address - Country:US
Practice Address - Phone:503-310-7591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL29421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical