Healthcare Provider Details

I. General information

NPI: 1588573539
Provider Name (Legal Business Name): JENNIFER RENEE KLOOSTERMAN-WALLS CADC-R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 NW 23RD ST
CORVALLIS OR
97330-5539
US

IV. Provider business mailing address

404 NW 23RD ST
CORVALLIS OR
97330-5539
US

V. Phone/Fax

Practice location:
  • Phone: 541-753-7801
  • Fax:
Mailing address:
  • Phone: 541-753-7801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: