Provider Demographics
NPI:1265949002
Name:WALSH, JILLIAN (LPCA)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5004 N MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3768
Mailing Address - Country:US
Mailing Address - Phone:617-838-0570
Mailing Address - Fax:
Practice Address - Street 1:3500 NE MARTIN LUTHER KING JR BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2093
Practice Address - Country:US
Practice Address - Phone:503-327-8205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
22-180221700000X
ORR9087101YP2500X
ORART-C-10231130221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist