Basic Information
| Provider Information | |||||||||
| NPI: | 1144585332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUHON | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 721 | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974700151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413750314 | ||||||||
| FaxNumber: | 5418964120 | ||||||||
| Practice Location | |||||||||
| Address1: | 1614 SE STEPHENS ST | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974704000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413750314 | ||||||||
| FaxNumber: | 5414403554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2012 | ||||||||
| LastUpdateDate: | 08/09/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C2891 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 500646807 | 05 | OR | MEDICAID |