Provider Demographics
NPI:1194179739
Name:RAWHOUSER, JENNIFER ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:RAWHOUSER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5112 NE 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-6333
Mailing Address - Country:US
Mailing Address - Phone:971-222-4976
Mailing Address - Fax:
Practice Address - Street 1:3939 NE HANCOCK ST STE 115
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-5321
Practice Address - Country:US
Practice Address - Phone:971-222-4976
Practice Address - Fax:971-346-4477
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL72221041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210418Medicaid