Provider Demographics
NPI:1851602825
Name:BOTT, JESSICA GRACE (CADCI, QMHA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:GRACE
Last Name:BOTT
Suffix:
Gender:F
Credentials:CADCI, QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 NW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3609
Mailing Address - Country:US
Mailing Address - Phone:503-294-1681
Mailing Address - Fax:503-241-7419
Practice Address - Street 1:709 NW EVERETT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3517
Practice Address - Country:US
Practice Address - Phone:503-226-4060
Practice Address - Fax:503-445-4913
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR08-12-04101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)