Provider Demographics
NPI:1215536750
Name:DUDLEY, JUSTINA ANNE
Entity Type:Individual
Prefix:
First Name:JUSTINA
Middle Name:ANNE
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19001 NW GREEN MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:BANKS
Mailing Address - State:OR
Mailing Address - Zip Code:97106-7305
Mailing Address - Country:US
Mailing Address - Phone:503-268-7352
Mailing Address - Fax:
Practice Address - Street 1:435 NE EVANS ST STE A
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-4628
Practice Address - Country:US
Practice Address - Phone:503-472-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-24
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health