Healthcare Provider Details

I. General information

NPI: 1063470987
Provider Name (Legal Business Name): TRACY MARIE JENDRITZA PSY D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACY MARIE MCDONALD

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 03/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 SW MACADAM AVE # 580
PORTLAND OR
97239-6103
US

IV. Provider business mailing address

5200 SW MACADAM AVE # 580
PORTLAND OR
97239-6103
US

V. Phone/Fax

Practice location:
  • Phone: 503-231-7854
  • Fax: 503-231-8153
Mailing address:
  • Phone: 503-231-7854
  • Fax: 503-231-8153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1631
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: