Healthcare Provider Details

I. General information

NPI: 1952027757
Provider Name (Legal Business Name): JACQUELINE MCGIVERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5744 E BURNSIDE ST STE 102
PORTLAND OR
97215-1499
US

IV. Provider business mailing address

3707 SE SALMON ST
PORTLAND OR
97214-4337
US

V. Phone/Fax

Practice location:
  • Phone: 708-528-5225
  • Fax:
Mailing address:
  • Phone: 708-528-5225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC4624
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: