Provider Demographics
NPI:1578725412
Name:WALSH, JENNIFER DAWN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:WALSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:DAWN
Other - Last Name:KEELING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1255 PEARL ST STE 102
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3570
Mailing Address - Country:US
Mailing Address - Phone:541-687-6983
Mailing Address - Fax:541-687-2063
Practice Address - Street 1:1255 PEARL ST STE 102
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3570
Practice Address - Country:US
Practice Address - Phone:541-687-6983
Practice Address - Fax:541-687-2063
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0859106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist