Provider Demographics
NPI:1609363720
Name:WHITT, JACQUELINE JAYE (THW, PWS, PSS)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:JAYE
Last Name:WHITT
Suffix:
Gender:F
Credentials:THW, PWS, PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8340 NE BROADWAY APT 310
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-5682
Mailing Address - Country:US
Mailing Address - Phone:503-839-0089
Mailing Address - Fax:
Practice Address - Street 1:21004 S HIGHWAY 213
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-9192
Practice Address - Country:US
Practice Address - Phone:503-839-0089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-14
Last Update Date:2018-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW0946101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW0946OtherOREGON HEALTH ATHORITY