Provider Demographics
NPI:1346961620
Name:HEINRICH, JOLENE G (MAT)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:G
Last Name:HEINRICH
Suffix:
Gender:F
Credentials:MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 SW JEFFERSON ST STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-7711
Mailing Address - Country:US
Mailing Address - Phone:503-539-4932
Mailing Address - Fax:503-297-5744
Practice Address - Street 1:2130 SW JEFFERSON ST STE 300
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-7711
Practice Address - Country:US
Practice Address - Phone:503-539-4932
Practice Address - Fax:503-297-5744
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR110285103TS0200X, 101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool