1528086055 NPI number — JACQUELINE J HEAD PSYD PC

Table of content: (NPI 1528086055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528086055 NPI number — JACQUELINE J HEAD PSYD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACQUELINE J HEAD PSYD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528086055
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22344 SW MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHERWOOD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97140-9416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-625-2768
Provider Business Mailing Address Fax Number:
503-625-3768

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22344 SW MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHERWOOD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97140-9416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-625-2768
Provider Business Practice Location Address Fax Number:
503-625-3768
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HEAD
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
503-625-2768

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  1328 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1639153125 . This is a "NPI, FOR IND. PROVIDER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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