Healthcare Provider Details

I. General information

NPI: 1538341508
Provider Name (Legal Business Name): JED GRODIN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5441 S MACADAM AVE # 8068
PORTLAND OR
97239-6106
US

IV. Provider business mailing address

5441 S MACADAM AVE # 8068
PORTLAND OR
97239-6106
US

V. Phone/Fax

Practice location:
  • Phone: 503-896-7122
  • Fax:
Mailing address:
  • Phone: 503-896-7122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2274
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: