Provider Demographics
NPI:1639658560
Name:GOLDSTEIN, JENNIFER R (MA, LPC INTERN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:GOLDSTEIN
Suffix:
Gender:F
Credentials:MA, LPC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 SE 11TH AVE STE 224
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1062
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2505 SE 11TH AVE STE 224
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1062
Practice Address - Country:US
Practice Address - Phone:971-570-8111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR5310101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health