Provider Demographics
NPI:1407994171
Name:ITZKOWITZ, JIMEE L (LCSW)
Entity Type:Individual
Prefix:
First Name:JIMEE
Middle Name:L
Last Name:ITZKOWITZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1652 NW HUGHWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-8844
Mailing Address - Country:US
Mailing Address - Phone:541-673-3985
Mailing Address - Fax:541-673-8060
Practice Address - Street 1:1652 NW HUGHWOOD CT
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8844
Practice Address - Country:US
Practice Address - Phone:541-673-3985
Practice Address - Fax:541-673-8060
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL33131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500695418Medicaid
OR500695418Medicaid
ORR115741Medicare PIN