Provider Demographics
NPI:1538332408
Name:MAGNESON, JENNIFER LEE (MS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:MAGNESON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16535 SW TUALATIN VALLEY HWY
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-5143
Mailing Address - Country:US
Mailing Address - Phone:503-649-5651
Mailing Address - Fax:503-649-7405
Practice Address - Street 1:16535 SW TUALATIN VALLEY HWY
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-5143
Practice Address - Country:US
Practice Address - Phone:503-649-5651
Practice Address - Fax:503-649-7405
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210855Medicaid