Provider Demographics
NPI:1790838258
Name:LURIE, JONATHAN (PHD, CADC III)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:LURIE
Suffix:
Gender:M
Credentials:PHD, CADC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10373 NE HANCOCK ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3873
Mailing Address - Country:US
Mailing Address - Phone:503-261-1850
Mailing Address - Fax:503-639-8044
Practice Address - Street 1:10373 NE HANCOCK ST
Practice Address - Street 2:SUITE 220
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3873
Practice Address - Country:US
Practice Address - Phone:503-261-1850
Practice Address - Fax:503-639-8044
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1302103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical