Provider Demographics
NPI:1770836934
Name:BRUNELLE, JESSICA (LPC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BRUNELLE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 NW COUNCIL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3725
Mailing Address - Country:US
Mailing Address - Phone:503-258-4281
Mailing Address - Fax:
Practice Address - Street 1:831 NW COUNCIL DR STE 300
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3725
Practice Address - Country:US
Practice Address - Phone:503-258-4281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-24
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274147Medicaid