Healthcare Provider Details

I. General information

NPI: 1063828259
Provider Name (Legal Business Name): SUSAN (SUE) MARIA MENEN JESSING PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 W ANCHOR AVE
EUGENE OR
97404-1601
US

IV. Provider business mailing address

98 W ANCHOR AVE
EUGENE OR
97404-1601
US

V. Phone/Fax

Practice location:
  • Phone: 541-505-6160
  • Fax: 866-203-1903
Mailing address:
  • Phone: 541-505-6160
  • Fax: 866-203-1903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number132050
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number10411871
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: