Provider Demographics
NPI:1417094129
Name:HARRISON, JESSICA CARMEN (BS, CADC I)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CARMEN
Last Name:HARRISON
Suffix:
Gender:F
Credentials:BS, CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 SE 127TH AVE
Mailing Address - Street 2:A233
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-3183
Mailing Address - Country:US
Mailing Address - Phone:503-872-0480
Mailing Address - Fax:503-872-0481
Practice Address - Street 1:9268 SE CLINTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-1456
Practice Address - Country:US
Practice Address - Phone:503-872-0480
Practice Address - Fax:503-872-0481
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORQMHA101Y00000X
OR105-11-25101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered171M00000XOther Service ProvidersCase Manager/Care Coordinator