MEDICARE: JILL ANNE GODICI LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	L3571	OR

General Provider Information

NPI Number	:	1558916460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILL ANNE GODICI LCSW

Provider Business Mailing Address
First Line	:	422 SE 79TH AVE STE 204
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97215-1519
Country	:	US
Telephone Number	:	503-473-9880
Fax Number	:

Provider Business Practice Location Address
First Line	:	422 SE 79TH AVE STE 204
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97215-1519
Country	:	US
Telephone Number	:	503-473-9880
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2019
Last Update Date	:	08/07/2019

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