Healthcare Provider Details

I. General information

NPI: 1639153125
Provider Name (Legal Business Name): JACQUELINE J HEAD PSY.D. PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 08/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22344 SW MAIN ST
SHERWOOD OR
97140-9416
US

IV. Provider business mailing address

22344 SW MAIN ST
SHERWOOD OR
97140-9416
US

V. Phone/Fax

Practice location:
  • Phone: 503-625-2768
  • Fax: 503-625-3768
Mailing address:
  • Phone: 503-625-2768
  • Fax: 503-625-3768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1328
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: