Provider Demographics
NPI:1003129115
Name:SAMSOM, JENNIFER D (MA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:D
Last Name:SAMSOM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2245 SW TROY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2657
Mailing Address - Country:US
Mailing Address - Phone:503-341-6393
Mailing Address - Fax:
Practice Address - Street 1:2245 SW TROY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2657
Practice Address - Country:US
Practice Address - Phone:503-341-6393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-17
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
ORC3886101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist