Provider Demographics
NPI:1326631060
Name:JOLLIFFE, MICHAEL DAVID (LPC INTERN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:JOLLIFFE
Suffix:
Gender:M
Credentials:LPC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3642 SE 33RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3488
Mailing Address - Country:US
Mailing Address - Phone:650-773-9674
Mailing Address - Fax:
Practice Address - Street 1:3642 SE 33RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3488
Practice Address - Country:US
Practice Address - Phone:650-773-9674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-13
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR6399101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health