Provider Demographics
NPI:1952710352
Name:DEAVILLE, JEANNINE DENIECE
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:DENIECE
Last Name:DEAVILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JEANNINE
Other - Middle Name:DENIECE
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:36 SW NYE ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-3821
Mailing Address - Country:US
Mailing Address - Phone:541-265-0581
Mailing Address - Fax:541-574-6252
Practice Address - Street 1:4909 S COAST HWY STE 1
Practice Address - Street 2:
Practice Address - City:SOUTH BEACH
Practice Address - State:OR
Practice Address - Zip Code:97366-9667
Practice Address - Country:US
Practice Address - Phone:541-574-5960
Practice Address - Fax:541-265-0601
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor