Provider Demographics
NPI:1720298656
Name:CARLSON, JEANNE LYNNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:LYNNE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25563
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97298-0563
Mailing Address - Country:US
Mailing Address - Phone:503-916-5681
Mailing Address - Fax:503-916-2655
Practice Address - Street 1:10531 SW CAPITOL HWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-6812
Practice Address - Country:US
Practice Address - Phone:503-916-5681
Practice Address - Fax:503-916-2655
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1252103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)