Provider Demographics
NPI:1700028883
Name:RICHIE, JENNIFER LYNN (LMSW)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYNN
Last Name:RICHIE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1703
Mailing Address - Country:US
Mailing Address - Phone:503-200-7055
Mailing Address - Fax:
Practice Address - Street 1:1132 SW 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1703
Practice Address - Country:US
Practice Address - Phone:503-200-7055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-03
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY077416251S00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1568401347OtherOUTSIDE IN