Healthcare Provider Details

I. General information

NPI: 1194500132
Provider Name (Legal Business Name): JESSICA SNOW LPC - ASSOCIATE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 SE 223RD AVE STE 165
GRESHAM OR
97030-2577
US

IV. Provider business mailing address

7610 SE 252ND AVE
GRESHAM OR
97080-7214
US

V. Phone/Fax

Practice location:
  • Phone: 971-404-4668
  • Fax: 971-273-2708
Mailing address:
  • Phone: 971-998-2901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR10864
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: