Provider Demographics
NPI:1164093738
Name:JAYANTI, MELAH (BA)
Entity Type:Individual
Prefix:
First Name:MELAH
Middle Name:
Last Name:JAYANTI
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 STATE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4541
Mailing Address - Country:US
Mailing Address - Phone:458-210-6739
Mailing Address - Fax:541-246-8826
Practice Address - Street 1:11740 SW 68TH PKWY STE 200
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-9058
Practice Address - Country:US
Practice Address - Phone:425-640-7009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORA140341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health