Provider Demographics
NPI:1912521998
Name:THE PRACTICE OF JEFFERY WISE THERAPEUTICS PMHNP-BC
Entity Type:Organization
Organization Name:THE PRACTICE OF JEFFERY WISE THERAPEUTICS PMHNP-BC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DNP, PMHNP-BC
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:503-781-5814
Mailing Address - Street 1:2651 NW THURMAN ST APT 303
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2327
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1834 NW 25TH AVE APT 504
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2764
Practice Address - Country:US
Practice Address - Phone:503-781-5814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-04
Last Update Date:2022-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)