Healthcare Provider Details

I. General information

NPI: 1386369783
Provider Name (Legal Business Name): KIMBERLY ANN JANKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2022
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 SW YAMHILL ST STE 300
PORTLAND OR
97204-3316
US

IV. Provider business mailing address

65 SW YAMHILL ST STE 300
PORTLAND OR
97204-3316
US

V. Phone/Fax

Practice location:
  • Phone: 503-878-8885
  • Fax: 971-297-1360
Mailing address:
  • Phone: 503-523-0296
  • Fax: 503-523-0296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSC61557302
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberA15306
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: