Provider Demographics
NPI:1982009320
Name:EASTLICK, JESSICA JEANNE (MA, CMHC)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:JEANNE
Last Name:EASTLICK
Suffix:
Gender:F
Credentials:MA, CMHC
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:JEANNE
Other - Last Name:SHAFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:230 N 3RD STREE SUITE 105
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97446-9679
Mailing Address - Country:US
Mailing Address - Phone:541-998-5660
Mailing Address - Fax:541-995-5013
Practice Address - Street 1:5051 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-6934
Practice Address - Country:US
Practice Address - Phone:541-357-4603
Practice Address - Fax:541-995-5013
Is Sole Proprietor?:No
Enumeration Date:2014-10-28
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR5085101YM0800X
101YM0800X
ORC7066101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500796326Medicaid