Provider Demographics
NPI:1619169695
Name:MALSTROM, JESSICA ROSE (CADCI, BA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ROSE
Last Name:MALSTROM
Suffix:
Gender:F
Credentials:CADCI, BA
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:ROSE
Other - Last Name:BONAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADCI, BA
Mailing Address - Street 1:9670 SW BEAVERTON HILLSDALE HWY
Mailing Address - Street 2:ANNEX B
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-3307
Mailing Address - Country:US
Mailing Address - Phone:503-626-9494
Mailing Address - Fax:503-646-8401
Practice Address - Street 1:9670 SW BEAVERTON HILLSDALE HWY
Practice Address - Street 2:ANNEX B
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3307
Practice Address - Country:US
Practice Address - Phone:503-626-9494
Practice Address - Fax:503-646-8401
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR195164Medicaid