Provider Demographics
NPI:1639676109
Name:HETLAND, JEREMY D (MA)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:D
Last Name:HETLAND
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 MEADOWS RD STE 150
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-0066
Mailing Address - Country:US
Mailing Address - Phone:503-726-5216
Mailing Address - Fax:
Practice Address - Street 1:5200 MEADOWS RD STE 150
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-0066
Practice Address - Country:US
Practice Address - Phone:503-726-5216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR4817101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health