Provider Demographics
NPI:1275926305
Name:MIATKE, JENNIFER (MA, LPC, MDIV, CADCI)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MIATKE
Suffix:
Gender:F
Credentials:MA, LPC, MDIV, CADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15097 HIGHWAY 66
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-9400
Mailing Address - Country:US
Mailing Address - Phone:541-613-2697
Mailing Address - Fax:541-245-1530
Practice Address - Street 1:18 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7309
Practice Address - Country:US
Practice Address - Phone:541-613-2697
Practice Address - Fax:541-245-1530
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-13
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3620101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health