Healthcare Provider Details

I. General information

NPI: 1710354279
Provider Name (Legal Business Name): JACQUELINE VAN DER ZWAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2015
Last Update Date: 09/17/2022
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 CLUB RD STE 350
EUGENE OR
97401-2599
US

IV. Provider business mailing address

66 CLUB RD STE 350
EUGENE OR
97401-2599
US

V. Phone/Fax

Practice location:
  • Phone: 541-343-1728
  • Fax:
Mailing address:
  • Phone: 541-343-1728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC4885
License Number StateOR

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: