Provider Demographics
NPI:1023252962
Name:CHANTARA, JENNA M (MSW, CADCII, QMHP)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:M
Last Name:CHANTARA
Suffix:
Gender:F
Credentials:MSW, CADCII, QMHP
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:M
Other - Last Name:NEVILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1027 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1328
Mailing Address - Country:US
Mailing Address - Phone:503-239-8400
Mailing Address - Fax:503-239-8407
Practice Address - Street 1:1027 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1328
Practice Address - Country:US
Practice Address - Phone:503-239-8400
Practice Address - Fax:503-239-8407
Is Sole Proprietor?:No
Enumeration Date:2009-04-22
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19-QMHPC-00131101YM0800X
104100000X
OR19-03-04101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker