Provider Demographics
NPI:1942613112
Name:ROHOLT, JENNIFER MICHELLE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:ROHOLT
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 1:18911 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-1630
Mailing Address - Country:US
Mailing Address - Phone:503-655-8471
Mailing Address - Fax:503-722-6810
Practice Address - Street 1:18911 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-1630
Practice Address - Country:US
Practice Address - Phone:503-556-8471
Practice Address - Fax:503-722-6810
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500691598Medicaid
OR106H00000XOtherMCFT