Healthcare Provider Details

I. General information

NPI: 1700966926
Provider Name (Legal Business Name): JONATHAN JOSEPH VALEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 SW 6TH AVE STE 602
PORTLAND OR
97204-1533
US

IV. Provider business mailing address

506 SW 6TH AVE STE 602
PORTLAND OR
97204-1533
US

V. Phone/Fax

Practice location:
  • Phone: 503-223-5537
  • Fax: 503-223-5584
Mailing address:
  • Phone: 503-223-5537
  • Fax: 503-223-5584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD22556
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier164936
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: