Provider Demographics
NPI:1396913331
Name:WALLIS, JASON DAVID (LPC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:DAVID
Last Name:WALLIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 NE MARTIN LUTHER KING JR BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2093
Mailing Address - Country:US
Mailing Address - Phone:503-655-8264
Mailing Address - Fax:503-953-2454
Practice Address - Street 1:2901 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1831
Practice Address - Country:US
Practice Address - Phone:503-953-0310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC7443101YP2500X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional