Provider Demographics
NPI:1689162471
Name:MITCHELL, JENNIFER MARIE (CRM)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:CRM
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:DOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 SE 160TH AVE APT 109
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-3569
Mailing Address - Country:US
Mailing Address - Phone:971-322-4341
Mailing Address - Fax:
Practice Address - Street 1:7916 SE FOSTER RD STE 201
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-4289
Practice Address - Country:US
Practice Address - Phone:503-465-2749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR16-CRM-194Medicaid