Healthcare Provider Details

I. General information

NPI: 1447337829
Provider Name (Legal Business Name): JENNIFER L. MIX LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5415 SW WESTGATE DR
PORTLAND OR
97221-2409
US

IV. Provider business mailing address

1078 SE 11TH AVE
HILLSBORO OR
97123-4796
US

V. Phone/Fax

Practice location:
  • Phone: 503-645-3581
  • Fax: 971-420-0297
Mailing address:
  • Phone: 512-560-9013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number20231
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC6625
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: