Basic Information
| Provider Information | |||||||||
| NPI: | 1942613112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROHOLT | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18911 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | GLADSTONE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970271630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036558471 | ||||||||
| FaxNumber: | 5037226810 | ||||||||
| Practice Location | |||||||||
| Address1: | 18911 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | GLADSTONE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970271630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035568471 | ||||||||
| FaxNumber: | 5037226810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2014 | ||||||||
| LastUpdateDate: | 01/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 500691598 | 05 | OR | MEDICAID | 106H00000X | 01 | OR | MCFT | OTHER |