Provider Demographics
NPI:1639153125
Name:HEAD, JACQUELINE J (PSYD PC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:J
Last Name:HEAD
Suffix:
Gender:F
Credentials:PSYD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22344 SW MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-9416
Mailing Address - Country:US
Mailing Address - Phone:503-625-2768
Mailing Address - Fax:503-625-3768
Practice Address - Street 1:22344 SW MAIN ST
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9416
Practice Address - Country:US
Practice Address - Phone:503-625-2768
Practice Address - Fax:503-625-3768
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1328103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP08205Medicare UPIN
ORR130749Medicare ID - Type UnspecifiedMEDICARE PROVIDER #