Provider Demographics
NPI:1255719886
Name:JENNICHES, MELISSA ELAINE (CADC I, QMHA I, CRM)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ELAINE
Last Name:JENNICHES
Suffix:
Gender:F
Credentials:CADC I, QMHA I, CRM
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:E
Other - Last Name:GOANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:QMHA, CRM
Mailing Address - Street 1:1160 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4143
Mailing Address - Country:US
Mailing Address - Phone:503-391-9762
Mailing Address - Fax:503-315-2019
Practice Address - Street 1:1160 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4143
Practice Address - Country:US
Practice Address - Phone:503-391-9762
Practice Address - Fax:503-315-2019
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR175T00000X
OR24-05-11138101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist