Healthcare Provider Details

I. General information

NPI: 1194534792
Provider Name (Legal Business Name): JAMIE KIDD
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2025
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11740 SW 68TH PKWY STE 200
TIGARD OR
97223-9058
US

IV. Provider business mailing address

5664 NW 183RD AVE APT A
PORTLAND OR
97229-3504
US

V. Phone/Fax

Practice location:
  • Phone: 503-389-0532
  • Fax:
Mailing address:
  • Phone: 503-389-0532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR9464
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: