Provider Demographics
NPI:1790275881
Name:MCDERMOND, JENNIFER LARISA (QMHA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LARISA
Last Name:MCDERMOND
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:CHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2311 NW VAN BUREN AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-5393
Mailing Address - Country:US
Mailing Address - Phone:541-230-1297
Mailing Address - Fax:541-368-3902
Practice Address - Street 1:2311 NW VAN BUREN AVE APT 5
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-5393
Practice Address - Country:US
Practice Address - Phone:541-230-1297
Practice Address - Fax:541-368-3902
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health