Provider Demographics
NPI:1801174305
Name:ULRICH, JENAE (PSYD)
Entity type:Individual
Prefix:
First Name:JENAE
Middle Name:
Last Name:ULRICH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 GARDEN AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97403-1934
Mailing Address - Country:US
Mailing Address - Phone:541-203-0984
Mailing Address - Fax:541-315-4835
Practice Address - Street 1:1901 GARDEN AVE STE 103
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97403-1934
Practice Address - Country:US
Practice Address - Phone:541-203-0984
Practice Address - Fax:541-315-4835
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2629103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500697905Medicaid