Provider Demographics
NPI:1770253783
Name:HERNANDEZ LOMELI, JESSICA JANETH
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JANETH
Last Name:HERNANDEZ LOMELI
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 1:7650 SW BEVELAND RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8692
Mailing Address - Country:US
Mailing Address - Phone:503-601-3615
Mailing Address - Fax:503-646-1683
Practice Address - Street 1:1508 DIVISION ST STE 205
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1585
Practice Address - Country:US
Practice Address - Phone:503-657-1071
Practice Address - Fax:503-657-3321
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA136581041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500812193Medicaid