Provider Demographics
NPI:1245306364
Name:JEDINY-RACIES, DANIELLE ELIZABETH (MFT)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:ELIZABETH
Last Name:JEDINY-RACIES
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 SW OAK ST
Mailing Address - Street 2:SUITE 520
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1817
Mailing Address - Country:US
Mailing Address - Phone:503-988-5464
Mailing Address - Fax:
Practice Address - Street 1:421 SW OAK ST
Practice Address - Street 2:SUITE 520
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-1817
Practice Address - Country:US
Practice Address - Phone:503-988-5464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC47705106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12019176OtherCAQH