Healthcare Provider Details

I. General information

NPI: 1316437387
Provider Name (Legal Business Name): MARCY IRENE JENKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15237 SE GLADSTONE ST
PORTLAND OR
97236-2485
US

IV. Provider business mailing address

15237 SE GLADSTONE ST
PORTLAND OR
97236-2485
US

V. Phone/Fax

Practice location:
  • Phone: 503-272-1656
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number201143228RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR5145
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: