Provider Demographics
NPI:1568035525
Name:RIEDL, JACEY ELLEN (LPC-INTERN)
Entity Type:Individual
Prefix:
First Name:JACEY
Middle Name:ELLEN
Last Name:RIEDL
Suffix:
Gender:F
Credentials:LPC-INTERN
Other - Prefix:
Other - First Name:JACEY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2145 NW TWILIGHT DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-5414
Mailing Address - Country:US
Mailing Address - Phone:303-868-5241
Mailing Address - Fax:541-639-8107
Practice Address - Street 1:BLISSFUL HEART WELLNESS CENTER
Practice Address - Street 2:29 NW GREELEY AVENUE
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-5414
Practice Address - Country:US
Practice Address - Phone:303-868-5241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR6395101YP2500X
ORC7786101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional