1518973015 NPI number — JENNIFER PENFIELD NELSON P.A.

Table of content: KELLY EBELS LMHCA (NPI 1447610274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518973015 NPI number — JENNIFER PENFIELD NELSON P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NELSON
Provider First Name:
JENNIFER
Provider Middle Name:
PENFIELD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PENFIELD
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518973015
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1945 NE JAMIE DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HILLSBORO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-679-9460
Provider Business Mailing Address Fax Number:
971-327-4356

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2111 NE 25TH AVE INTEL HEALTH FOR LIFE CENTER
Provider Second Line Business Practice Location Address:
MS:JF-167
Provider Business Practice Location Address City Name:
HILLSBORO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-264-8315
Provider Business Practice Location Address Fax Number:
503-264-0559
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA00813 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 00813 , 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: 500617236 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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