Provider Demographics
NPI:1295240190
Name:JACONIS, MARYANNE (PHD)
Entity type:Individual
Prefix:DR
First Name:MARYANNE
Middle Name:
Last Name:JACONIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1742 SE CLATSOP ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-7305
Mailing Address - Country:US
Mailing Address - Phone:503-908-3767
Mailing Address - Fax:
Practice Address - Street 1:1742 SE CLATSOP ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-7305
Practice Address - Country:US
Practice Address - Phone:503-908-3767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2882103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical