Provider Demographics
NPI:1881370153
Name:DOUGLAS, JAE PATRICIA (LMSW, PHD)
Entity type:Individual
Prefix:DR
First Name:JAE
Middle Name:PATRICIA
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LMSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9805 NE SHAVER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3651
Mailing Address - Country:US
Mailing Address - Phone:503-860-7589
Mailing Address - Fax:
Practice Address - Street 1:9805 NE SHAVER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3651
Practice Address - Country:US
Practice Address - Phone:503-860-7589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORM13927101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health