Provider Demographics
NPI:1891418968
Name:DEIDRICH, JENNAFER ROSE (FAMILY PEER SUPPORT)
Entity Type:Individual
Prefix:
First Name:JENNAFER
Middle Name:ROSE
Last Name:DEIDRICH
Suffix:
Gender:F
Credentials:FAMILY PEER SUPPORT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S J ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1623
Mailing Address - Country:US
Mailing Address - Phone:541-947-6021
Mailing Address - Fax:
Practice Address - Street 1:700 S J ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1623
Practice Address - Country:US
Practice Address - Phone:541-947-6021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHA-R-3371171M00000X
OR107865175T00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator