Provider Demographics
NPI:1265680524
Name:KING, JENNIFER JOANNE (MSW, RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JOANNE
Last Name:KING
Suffix:
Gender:F
Credentials:MSW, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7408 SE CLAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3531
Mailing Address - Country:US
Mailing Address - Phone:503-442-5491
Mailing Address - Fax:
Practice Address - Street 1:58646 MCNULTY WAY
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-6210
Practice Address - Country:US
Practice Address - Phone:503-397-5211
Practice Address - Fax:503-397-5373
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA3451101Y00000X
OR200842224RN163W00000X, 163WH0200X, 163WP0809X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult