1558498428 NPI number — JENNIFER GOMOLL DAUGHERTY LPC, LMHC

Table of content: JENNIFER GOMOLL DAUGHERTY LPC, LMHC (NPI 1558498428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558498428 NPI number — JENNIFER GOMOLL DAUGHERTY LPC, LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAUGHERTY
Provider First Name:
JENNIFER
Provider Middle Name:
GOMOLL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, LMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOMOLL
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
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:
1558498428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3519 NE 15TH
Provider Second Line Business Mailing Address:
SUITE 547
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-226-4827
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3519 NE 15TH
Provider Second Line Business Practice Location Address:
SUITE 547
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-750-7436
Provider Business Practice Location Address Fax Number:
503-926-9182
Provider Enumeration Date:
02/27/2007

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: 101YP2500X , with the licence number:  60638897 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: C1929 , 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)





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