Provider Demographics
NPI:1144616665
Name:CORP, JESSICA (MS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CORP
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SE 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1200
Mailing Address - Country:US
Mailing Address - Phone:503-235-0131
Mailing Address - Fax:
Practice Address - Street 1:200 SE 7TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1200
Practice Address - Country:US
Practice Address - Phone:503-235-0131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR2910101YM0800X
OR16-05-05101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR2910OtherOREGON BOARD OF COUNSELORS, REGISTERED INTERN