Healthcare Provider Details

I. General information

NPI: 1710398425
Provider Name (Legal Business Name): KIMBERLY M. JAYNE PHD, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2014
Last Update Date: 11/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6902 SE LAKE RD STE 202
MILWAUKIE OR
97267-2148
US

IV. Provider business mailing address

6902 SE LAKE RD STE 202
MILWAUKIE OR
97267-2148
US

V. Phone/Fax

Practice location:
  • Phone: 503-652-2810
  • Fax:
Mailing address:
  • Phone: 503-652-2810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC3880
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: