Provider Demographics
NPI:1841079803
Name:RUSSELL, PEGGY JAYNE (MC, PCA)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:JAYNE
Last Name:RUSSELL
Suffix:
Gender:
Credentials:MC, PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12930 SE 162ND AVE UNIT 305
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-4744
Mailing Address - Country:US
Mailing Address - Phone:503-698-0628
Mailing Address - Fax:
Practice Address - Street 1:12930 SE 162ND AVE UNIT 305
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-4744
Practice Address - Country:US
Practice Address - Phone:503-698-0628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR8718101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health