Healthcare Provider Details

I. General information

NPI: 1568002392
Provider Name (Legal Business Name): JENNIFER LIANA SIEGEL CADC-2
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 NW BETHANY BLVD STE 320
BEAVERTON OR
97006-5238
US

IV. Provider business mailing address

1500 NW BETHANY BLVD STE 320
BEAVERTON OR
97006-5238
US

V. Phone/Fax

Practice location:
  • Phone: 503-567-3260
  • Fax:
Mailing address:
  • Phone: 503-567-3260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number24-04-20412
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberTHW000003996
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22-02-10336
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: