Healthcare Provider Details

I. General information

NPI: 1295106482
Provider Name (Legal Business Name): JODI ELIZABETH JOHNSON PALENSKY PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2015
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 SW MARLOW AVE SUITE 110
PORTLAND OR
97225-5185
US

IV. Provider business mailing address

1815 SW MARLOW AVE SUITE 110
PORTLAND OR
97225-5185
US

V. Phone/Fax

Practice location:
  • Phone: 503-292-0765
  • Fax: 503-292-5208
Mailing address:
  • Phone: 503-292-0765
  • Fax: 503-292-5208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2306
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: