Provider Demographics
NPI:1770784274
Name:JENNINGS, JOHN (CADC II)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 SW 171ST PL
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4300
Mailing Address - Country:US
Mailing Address - Phone:415-309-4500
Mailing Address - Fax:
Practice Address - Street 1:2415 SE 43RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1600
Practice Address - Country:US
Practice Address - Phone:503-230-9654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11-R-10101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)