Healthcare Provider Details

I. General information

NPI: 1306560248
Provider Name (Legal Business Name): JENETTE MUNDLIN LPC ASSOC, CRC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 NE 2ND ST
GRESHAM OR
97030-7512
US

IV. Provider business mailing address

PO BOX 955
GRESHAM OR
97030-0210
US

V. Phone/Fax

Practice location:
  • Phone: 971-373-6486
  • Fax:
Mailing address:
  • Phone: 971-737-6486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR7908
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: