Provider Demographics
NPI:1912045139
Name:FANNING, JEANETTE MARIE (QMHA)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:MARIE
Last Name:FANNING
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9515 SE 74TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97222-1817
Mailing Address - Country:US
Mailing Address - Phone:503-708-9256
Mailing Address - Fax:503-243-2429
Practice Address - Street 1:2375 NW GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3420
Practice Address - Country:US
Practice Address - Phone:503-243-2236
Practice Address - Fax:503-243-2429
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Not Answered171M00000XOther Service ProvidersCase Manager/Care Coordinator