Provider Demographics
NPI:1700865490
Name:GEDDES, JACQUELINE LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:LEE
Last Name:GEDDES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:QUILLAN
Other - Middle Name:
Other - Last Name:GEDDES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:11630 SE 40TH AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-6195
Mailing Address - Country:US
Mailing Address - Phone:503-739-5365
Mailing Address - Fax:971-231-1420
Practice Address - Street 1:11630 SE 40TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6195
Practice Address - Country:US
Practice Address - Phone:503-739-5365
Practice Address - Fax:971-231-1420
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00003673103T00000X
OR2366103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR50068100OtherDMAP