Provider Demographics
NPI:1336679448
Name:FORMWAY-NELSON, JAELITHE AZURE
Entity Type:Individual
Prefix:
First Name:JAELITHE
Middle Name:AZURE
Last Name:FORMWAY-NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAELITHE
Other - Middle Name:AZURE
Other - Last Name:FORMWAY-HUBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8915 SW CENTER ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6307
Mailing Address - Country:US
Mailing Address - Phone:503-726-3690
Mailing Address - Fax:
Practice Address - Street 1:8915 SW CENTER ST.
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223
Practice Address - Country:US
Practice Address - Phone:503-726-3690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health