Healthcare Provider Details

I. General information

NPI: 1437741691
Provider Name (Legal Business Name): JENNIFER N FISHER CSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNI N GOODRIDGE CASE MANAGER

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

YELLOWHAWK TRIBAL HEALTH CENTER 46314 TIMINE WAY
PENDLETON OR
97801
US

IV. Provider business mailing address

YELLOWHAWK TRIBAL HEALTH CENTER 46314 TIMINE WAY
PENDLETON OR
97801
US

V. Phone/Fax

Practice location:
  • Phone: 541-966-9830
  • Fax:
Mailing address:
  • Phone: 541-966-9830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA13788
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAI3788
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: