Healthcare Provider Details

I. General information

NPI: 1104766765
Provider Name (Legal Business Name): SISKIYOU PSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 W 9TH ST
MEDFORD OR
97501-3135
US

IV. Provider business mailing address

PO BOX 1787
MEDFORD OR
97501-0261
US

V. Phone/Fax

Practice location:
  • Phone: 888-556-7282
  • Fax: 458-203-5051
Mailing address:
  • Phone: 888-556-7282
  • Fax: 458-203-5051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: JENNIFER MATHEWS
Title or Position: OWNER
Credential:
Phone: 314-757-4969