Basic Information
| Provider Information | |||||||||
| NPI: | 1003316043 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOM | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | THOM | ||||||||
| OtherFirstName: | JENNY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10700 SW BEAVERTON HILLSDALE HWY | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970053019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036411475 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10700 SW BEAVERTON HILLSDALE HWY | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036411475 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2018 | ||||||||
| LastUpdateDate: | 10/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C6096 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.