Provider Demographics
NPI:1245006394
Name:LUTE, JACQUELYN DALE (BA, AMS)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:DALE
Last Name:LUTE
Suffix:
Gender:F
Credentials:BA, AMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 SE LAKE RD STE 175
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2137
Mailing Address - Country:US
Mailing Address - Phone:682-250-7500
Mailing Address - Fax:
Practice Address - Street 1:12910 SE 137TH DR
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-5873
Practice Address - Country:US
Practice Address - Phone:503-756-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty