Healthcare Provider Details

I. General information

NPI: 1528254018
Provider Name (Legal Business Name): JENNIFER O'SULLIVAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER FAULCONER

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2660 NE HIGHWAY 20 STE 610-437
BEND OR
97701-6402
US

IV. Provider business mailing address

3026 NE LARAMIE WAY
BEND OR
97701-6270
US

V. Phone/Fax

Practice location:
  • Phone: 541-728-3171
  • Fax:
Mailing address:
  • Phone: 541-728-3171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW60668237
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL4477
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW27793
License Number StateCA

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: