Provider Demographics
NPI:1881052876
Name:JENNINGS, LISA MARIE (MSW,QMHP, CSWA, CADC)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:MSW,QMHP, CSWA, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SW BRANTLEY DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON
Mailing Address - State:OR
Mailing Address - Zip Code:97496-4526
Mailing Address - Country:US
Mailing Address - Phone:541-679-0366
Mailing Address - Fax:541-679-4821
Practice Address - Street 1:11 SW BRANTLEY DR
Practice Address - Street 2:
Practice Address - City:WINSTON
Practice Address - State:OR
Practice Address - Zip Code:97496-4526
Practice Address - Country:US
Practice Address - Phone:541-679-0366
Practice Address - Fax:541-679-4821
Is Sole Proprietor?:No
Enumeration Date:2016-02-04
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15-02-24101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)