Provider Demographics
NPI:1134287451
Name:HAGEN, JENNIE B (MA)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:B
Last Name:HAGEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:JENNIE
Other - Middle Name:L
Other - Last Name:BARNHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:9120 NE 66TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-4420
Mailing Address - Country:US
Mailing Address - Phone:503-622-9140
Mailing Address - Fax:
Practice Address - Street 1:2705 E BURNSIDE ST
Practice Address - Street 2:SUITE 206
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1763
Practice Address - Country:US
Practice Address - Phone:503-622-9140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3345101YP2500X
WALH60321408101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health