Provider Demographics
NPI:1790452589
Name:ROBERTSEN, JONNA
Entity Type:Individual
Prefix:
First Name:JONNA
Middle Name:
Last Name:ROBERTSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:ROBERTSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:23633 HIGHWAY 62 APT 1
Mailing Address - Street 2:
Mailing Address - City:SHADY COVE
Mailing Address - State:OR
Mailing Address - Zip Code:97539-7706
Mailing Address - Country:US
Mailing Address - Phone:541-778-3611
Mailing Address - Fax:
Practice Address - Street 1:23633 HIGHWAY 62 APT 1
Practice Address - Street 2:
Practice Address - City:SHADY COVE
Practice Address - State:OR
Practice Address - Zip Code:97539-7706
Practice Address - Country:US
Practice Address - Phone:541-778-3611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-27
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHA-R-3993101YM0800X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist