Basic Information
| Provider Information | |||||||||
| NPI: | 1962716936 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRYAN | ||||||||
| OtherFirstName: | EMILY | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.A. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 100 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973210031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419673866 | ||||||||
| FaxNumber: | 5418128807 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973553109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414515932 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2010 | ||||||||
| LastUpdateDate: | 02/04/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.