Provider Demographics
NPI:1750727483
Name:SHANNON, JACQUELINE RIEGELHAUPT-KAMRIN (LMFT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RIEGELHAUPT-KAMRIN
Last Name:SHANNON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 NE 79TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-7007
Mailing Address - Country:US
Mailing Address - Phone:619-674-9525
Mailing Address - Fax:
Practice Address - Street 1:313 NE 79TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-7007
Practice Address - Country:US
Practice Address - Phone:619-674-9525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20-R-29101YA0400X
CA116706106H00000X
171M00000X
ORT1773106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator