Provider Demographics
NPI:1164681722
Name:LOUGH, JESSE E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:E
Last Name:LOUGH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16189 SW HOLLAND LN
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-9436
Mailing Address - Country:US
Mailing Address - Phone:503-704-3895
Mailing Address - Fax:
Practice Address - Street 1:1830 NE GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3912
Practice Address - Country:US
Practice Address - Phone:503-704-3895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-08
Last Update Date:2010-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1823103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical