Provider Demographics
NPI:1518146802
Name:PREMO, JANICE C
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:C
Last Name:PREMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:
Other - Last Name:PREMO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LPC, CADC1,CRC
Mailing Address - Street 1:6400 SE LAKE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2129
Mailing Address - Country:US
Mailing Address - Phone:503-810-8111
Mailing Address - Fax:
Practice Address - Street 1:6400 SE LAKE RD STE 102
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97222-2129
Practice Address - Country:US
Practice Address - Phone:503-810-8111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-02
Last Update Date:2007-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2044101YP2500X
OR85365101YP2500X
OR07-09-36101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR07-09-36OtherCADC1