Provider Demographics
NPI:1841359601
Name:NEIHEISEL, JOHN KENT (MSW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:KENT
Last Name:NEIHEISEL
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4403 SW 47TH DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-3734
Mailing Address - Country:US
Mailing Address - Phone:503-227-4722
Mailing Address - Fax:503-295-7898
Practice Address - Street 1:1962 NW KEARNEY ST STE L102
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1459
Practice Address - Country:US
Practice Address - Phone:503-525-1148
Practice Address - Fax:503-295-7898
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR05701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical