Provider Demographics
NPI:1396480893
Name:PETTY, JENNIFER NICOLE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:PETTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 SW ALDER ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-3620
Mailing Address - Country:US
Mailing Address - Phone:503-418-5311
Mailing Address - Fax:503-494-4747
Practice Address - Street 1:621 SW ALDER ST STE 520
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-3620
Practice Address - Country:US
Practice Address - Phone:503-418-5311
Practice Address - Fax:503-494-4747
Is Sole Proprietor?:No
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR101YM0800XMedicaid