Provider Demographics
NPI:1689200784
Name:JAEGER-MANSON, SOPHIA (PSYD)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:JAEGER-MANSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3370 ELDER ST NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3294
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 CENTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2669
Practice Address - Country:US
Practice Address - Phone:503-947-8093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2910103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic