Healthcare Provider Details

I. General information

NPI: 1669291290
Provider Name (Legal Business Name): JENNER WARREN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 NE MLK BLVD
PORTLAND OR
97232-3578
US

IV. Provider business mailing address

5131 SW 38TH PL APT 47
PORTLAND OR
97221-3832
US

V. Phone/Fax

Practice location:
  • Phone: 971-350-1122
  • Fax:
Mailing address:
  • Phone: 801-674-2587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR9867
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: