Healthcare Provider Details

I. General information

NPI: 1861689978
Provider Name (Legal Business Name): MARY JAYNE WYKOWSKI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2007
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 SE 43RD AVE
PORTLAND OR
97206-1600
US

IV. Provider business mailing address

2935 NW 154TH AVE
BEAVERTON OR
97006-5351
US

V. Phone/Fax

Practice location:
  • Phone: 503-872-0168
  • Fax:
Mailing address:
  • Phone: 503-312-5181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL4960
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: