Provider Demographics
NPI:1649641929
Name:MATHISEN, JENNIFER L
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:MATHISEN
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 1:1407 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3070
Mailing Address - Country:US
Mailing Address - Phone:541-340-0949
Mailing Address - Fax:541-386-5440
Practice Address - Street 1:500 WASHINGTON ST STE B
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-2217
Practice Address - Country:US
Practice Address - Phone:541-340-0949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health