Healthcare Provider Details

I. General information

NPI: 1780732420
Provider Name (Legal Business Name): JESSIE L DIAMOND LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 SE 12TH AVE
PORTLAND OR
97214-2513
US

IV. Provider business mailing address

4506 SE HARRISON ST.
MILWAUKIE OR
97222-5272
US

V. Phone/Fax

Practice location:
  • Phone: 503-997-7910
  • Fax:
Mailing address:
  • Phone: 503-997-7910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC1496
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: