Healthcare Provider Details

I. General information

NPI: 1063329779
Provider Name (Legal Business Name): AUTHENTIC PSYCHIATRIC WELLBEING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6305 FERRY ST # 2
PACIFIC CITY OR
97135-8000
US

IV. Provider business mailing address

PO BOX 839
PACIFIC CITY OR
97135-0839
US

V. Phone/Fax

Practice location:
  • Phone: 503-932-7808
  • Fax: 503-584-4253
Mailing address:
  • Phone: 503-932-7808
  • Fax: 503-584-4253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JASON ELLIOTT
Title or Position: SOLE MEMBER
Credential: PMHNP-C
Phone: 503-932-7808