Healthcare Provider Details

I. General information

NPI: 1265949002
Provider Name (Legal Business Name): JILLIAN WALSH LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2018
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 NE MARTIN LUTHER KING JR BLVD STE 200
PORTLAND OR
97212-2093
US

IV. Provider business mailing address

5004 N MONTANA AVE
PORTLAND OR
97217-3768
US

V. Phone/Fax

Practice location:
  • Phone: 503-327-8205
  • Fax:
Mailing address:
  • Phone: 617-838-0570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number22-180
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberR9087
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License NumberART-C-10231130
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: