Provider Demographics
NPI:1982008579
Name:CORK, JENNIFER (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CORK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 EAGLE VIEW DR NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-4253
Mailing Address - Country:US
Mailing Address - Phone:208-301-8975
Mailing Address - Fax:
Practice Address - Street 1:5285 MEADOWS RD STE 170
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3478
Practice Address - Country:US
Practice Address - Phone:503-726-5216
Practice Address - Fax:503-726-5218
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-362861041C0700X
ORL130531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical