Provider Demographics
NPI:1639997034
Name:COOMES, JENNIFER (MED, LSC, QMHP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:COOMES
Suffix:
Gender:F
Credentials:MED, LSC, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 SE 121ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-1028
Mailing Address - Country:US
Mailing Address - Phone:503-201-8329
Mailing Address - Fax:
Practice Address - Street 1:2811 SE 121ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-1028
Practice Address - Country:US
Practice Address - Phone:503-201-8329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR124916101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool