Healthcare Provider Details

I. General information

NPI: 1174403299
Provider Name (Legal Business Name): JENNIFER WEISS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5441 S MACADAM AVE STE R
PORTLAND OR
97239-3822
US

IV. Provider business mailing address

5441 S MACADAM AVE STE R
PORTLAND OR
97239-3822
US

V. Phone/Fax

Practice location:
  • Phone: 458-313-0616
  • Fax:
Mailing address:
  • Phone: 458-313-0616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberR9820
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: