Provider Demographics
NPI:1932458866
Name:NIEDERKORN, JAYNE
Entity Type:Individual
Prefix:
First Name:JAYNE
Middle Name:
Last Name:NIEDERKORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4531 SE BELMONT STREET
Mailing Address - Street 2:STE 100
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1675
Mailing Address - Country:US
Mailing Address - Phone:503-215-6556
Mailing Address - Fax:
Practice Address - Street 1:4531 SE BELMONT STREET
Practice Address - Street 2:STE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1675
Practice Address - Country:US
Practice Address - Phone:503-215-6556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1221101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional