Healthcare Provider Details

I. General information

NPI: 1700865490
Provider Name (Legal Business Name): JACQUELINE LEE GEDDES PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: QUILLAN GEDDES PHD

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11630 SE 40TH AVE SUITE A
MILWAUKIE OR
97222-6195
US

IV. Provider business mailing address

11630 SE 40TH AVE SUITE A
MILWAUKIE OR
97222-6195
US

V. Phone/Fax

Practice location:
  • Phone: 503-739-5365
  • Fax: 971-231-1420
Mailing address:
  • Phone: 503-739-5365
  • Fax: 971-231-1420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY00003673
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2366
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: