Healthcare Provider Details

I. General information

NPI: 1669348082
Provider Name (Legal Business Name): TAILESE SWANSON COUNSELING STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7044 SW GONZAGA ST UNIT 101
PORTLAND OR
97223-8303
US

IV. Provider business mailing address

PO BOX 1228
JACKSONVILLE OR
97530-1228
US

V. Phone/Fax

Practice location:
  • Phone: 503-720-3276
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number8884
License Number State
# 2
Primary TaxonomyN
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number128292
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: