Healthcare Provider Details

I. General information

NPI: 1407300205
Provider Name (Legal Business Name): JENNA ABERNATHY MA, LPC INTERN, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3537 N WILLIAMS AVE
PORTLAND OR
97227
US

IV. Provider business mailing address

4545 NE MALLORY AVE
PORTLAND OR
97211-3330
US

V. Phone/Fax

Practice location:
  • Phone: 503-309-8622
  • Fax:
Mailing address:
  • Phone: 503-309-8622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number10987
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: