Provider Demographics
NPI:1437810538
Name:MINDFUL THERAPY PACIFIC NW, LLC
Entity Type:Organization
Organization Name:MINDFUL THERAPY PACIFIC NW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMSOM
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LMHC
Authorized Official - Phone:503-341-6393
Mailing Address - Street 1:2245 SW TROY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2657
Mailing Address - Country:US
Mailing Address - Phone:503-341-6393
Mailing Address - Fax:888-920-2077
Practice Address - Street 1:2245 SW TROY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2657
Practice Address - Country:US
Practice Address - Phone:503-341-6393
Practice Address - Fax:888-920-2077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-01
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1003129115Medicaid