Healthcare Provider Details

I. General information

NPI: 1124259411
Provider Name (Legal Business Name): JANINE FERGUSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9700 SW BEAVERTON HILLSDALE HWY
BEAVERTON OR
97005-3306
US

IV. Provider business mailing address

PO BOX 82819
PORTLAND OR
97282-0819
US

V. Phone/Fax

Practice location:
  • Phone: 503-626-9494
  • Fax: 503-646-5671
Mailing address:
  • Phone: 503-233-5405
  • Fax: 503-233-2692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11-06-24
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: