Healthcare Provider Details

I. General information

NPI: 1275719163
Provider Name (Legal Business Name): JENNIFER PAYNE BOONE M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61050 SYDNEY HARBOR DR
BEND OR
97702
US

IV. Provider business mailing address

61141 S HWY 97 # 637
BEND OR
97702-2523
US

V. Phone/Fax

Practice location:
  • Phone: 541-728-7375
  • Fax:
Mailing address:
  • Phone: 541-728-7375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

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

# 1
IdentifierC2746
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerLICENSED PROFESSIONAL COUNSLOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: