Provider Demographics
NPI:1558498428
Name:DAUGHERTY, JENNIFER GOMOLL (LPC, LMHC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GOMOLL
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:LPC, LMHC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:GOMOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3519 NE 15TH
Mailing Address - Street 2:SUITE 547
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212
Mailing Address - Country:US
Mailing Address - Phone:360-226-4827
Mailing Address - Fax:
Practice Address - Street 1:3519 NE 15TH
Practice Address - Street 2:SUITE 547
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212
Practice Address - Country:US
Practice Address - Phone:503-750-7436
Practice Address - Fax:503-926-9182
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60638897101YP2500X
ORC1929101YP2500X, 101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)