Healthcare Provider Details

I. General information

NPI: 1497188858
Provider Name (Legal Business Name): JENNIFER U BOGGS LCSW, CADC I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. JENNIFER ULLAKKO

II. Dates (important events)

Enumeration Date: 08/20/2013
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 PIER 1 STE 203
ASTORIA OR
97103
US

IV. Provider business mailing address

PO BOX 286
NASELLE WA
98638-0286
US

V. Phone/Fax

Practice location:
  • Phone: 503-994-6394
  • Fax: 503-386-2042
Mailing address:
  • Phone: 503-994-6394
  • Fax: 503-386-2042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number08-08-05
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW 60297208
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL5767
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: