Healthcare Provider Details

I. General information

NPI: 1952866337
Provider Name (Legal Business Name): JESSICA KABAO XIONG MA, LPC, NLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA KABAO VANG

II. Dates (important events)

Enumeration Date: 02/09/2019
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5305 RIVER RD N STE B
KEIZER OR
97303-5324
US

IV. Provider business mailing address

5305 RIVER RD N STE B
KEIZER OR
97303-5324
US

V. Phone/Fax

Practice location:
  • Phone: 770-361-4523
  • Fax:
Mailing address:
  • Phone: 770-361-4523
  • 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 Code101YM0800X
TaxonomyMental Health Counselor
License NumberC6594
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: