Healthcare Provider Details

I. General information

NPI: 1912816703
Provider Name (Legal Business Name): JESSE DAKOTAH LAWRENCE-PINE PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2026
Last Update Date: 09/05/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9014 N WALL AVE
PORTLAND OR
97203-2658
US

IV. Provider business mailing address

9014 N WALL AVE
PORTLAND OR
97203-2658
US

V. Phone/Fax

Practice location:
  • Phone: 503-545-5508
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10066659
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: