Provider Demographics
NPI:1841236544
Name:ROSSI, JENNIFER RENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:RENE
Last Name:ROSSI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 734
Mailing Address - Street 2:
Mailing Address - City:REEDSPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97467-0734
Mailing Address - Country:US
Mailing Address - Phone:541-662-0527
Mailing Address - Fax:541-271-9502
Practice Address - Street 1:3520 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:REEDSPORT
Practice Address - State:OR
Practice Address - Zip Code:97467-1738
Practice Address - Country:US
Practice Address - Phone:541-662-0527
Practice Address - Fax:541-271-9502
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1602103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR130604Medicare PIN