Provider Demographics
NPI:1285626507
Name:ANTICK, JENNIFER R (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:ANTICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:UHN 80
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-7353
Mailing Address - Fax:503-494-3282
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:UHN 80
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-7353
Practice Address - Fax:503-494-3282
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002039103TC0700X
OR1853103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7099252Medicaid
AB26605Medicare ID - Type Unspecified
WA7099252Medicaid