Provider Demographics
NPI:1790496784
Name:JESSUP, STEPHANIE MARIE HUMIWAT
Entity Type:Individual
Prefix:
First Name:STEPHANIE MARIE
Middle Name:HUMIWAT
Last Name:JESSUP
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 1:415 SE 108TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-3127
Mailing Address - Country:US
Mailing Address - Phone:916-753-9211
Mailing Address - Fax:
Practice Address - Street 1:415 SE 108TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-3127
Practice Address - Country:US
Practice Address - Phone:916-753-9211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORABA-IN-10227793106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician