Provider Demographics
NPI:1669291290
Name:WARREN, JENNER
Entity type:Individual
Prefix:
First Name:JENNER
Middle Name:
Last Name:WARREN
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5131 SW 38TH PL APT 47
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-3832
Mailing Address - Country:US
Mailing Address - Phone:801-674-2587
Mailing Address - Fax:
Practice Address - Street 1:11 NE MLK BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3578
Practice Address - Country:US
Practice Address - Phone:971-350-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR9867101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health