Provider Demographics
NPI:1720554199
Name:TOBIN, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:TOBIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9115 SW OLESON RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6875
Mailing Address - Country:US
Mailing Address - Phone:541-977-2300
Mailing Address - Fax:
Practice Address - Street 1:9115 SW OLESON RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-6875
Practice Address - Country:US
Practice Address - Phone:541-977-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherCENTER FOR SOCIAL DYNAMICS