Provider Demographics
NPI:1336614502
Name:TRAVIS, JENNIFER L (QMHP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:QMHP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:KRIGBAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 176
Mailing Address - Street 2:
Mailing Address - City:WHEELER
Mailing Address - State:OR
Mailing Address - Zip Code:97147-0176
Mailing Address - Country:US
Mailing Address - Phone:800-368-5182
Mailing Address - Fax:541-889-7873
Practice Address - Street 1:230 ROWE RD
Practice Address - Street 2:
Practice Address - City:WHEELER
Practice Address - State:OR
Practice Address - Zip Code:97147-0035
Practice Address - Country:US
Practice Address - Phone:800-368-5182
Practice Address - Fax:844-712-3001
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
ORA12846104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical