Healthcare Provider Details

I. General information

NPI: 1902131352
Provider Name (Legal Business Name): JANETTE FAY MYDLAND MS, C10678
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2009
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 W MADRONE ST
ROSEBURG OR
97470-3090
US

IV. Provider business mailing address

621 W MADRONE ST
ROSEBURG OR
97470-3090
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-3532
  • Fax:
Mailing address:
  • Phone: 541-440-3532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberQMHPC-001646
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-2465
License Number StateWY
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC10678
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-1293
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: