Provider Demographics
NPI:1639912546
Name:DE CLERCK, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DE CLERCK
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 1:1525 SE 44TH AVE APT 403
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3176
Mailing Address - Country:US
Mailing Address - Phone:971-386-3195
Mailing Address - Fax:
Practice Address - Street 1:1215 SW 18TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1711
Practice Address - Country:US
Practice Address - Phone:971-238-4789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor