Provider Demographics
NPI:1346746658
Name:MACK, ASHLEY JESSICA
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:JESSICA
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11424 SW BULL MOUNTAIN RD APT 314
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-2979
Mailing Address - Country:US
Mailing Address - Phone:408-483-5585
Mailing Address - Fax:
Practice Address - Street 1:1520 PLAZA ST NW STE 150
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-4658
Practice Address - Country:US
Practice Address - Phone:503-585-3012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health