1568035525 NPI number — JACEY ELLEN RIEDL LPC-INTERN

Table of content: JACEY ELLEN RIEDL LPC-INTERN (NPI 1568035525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568035525 NPI number — JACEY ELLEN RIEDL LPC-INTERN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIEDL
Provider First Name:
JACEY
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC-INTERN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
JACEY
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:
1568035525
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2145 NW TWILIGHT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97703-5414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-868-5241
Provider Business Mailing Address Fax Number:
541-639-8107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BLISSFUL HEART WELLNESS CENTER
Provider Second Line Business Practice Location Address:
29 NW GREELEY AVENUE
Provider Business Practice Location Address City Name:
BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97703-5414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-868-5241
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2021

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:  R6395 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: C7786 , 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)