Healthcare Provider Details

I. General information

NPI: 1104641653
Provider Name (Legal Business Name): NIKKI ILENE PENNISH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7320 SW HUNZIKER RD STE 201
TIGARD OR
97223-2301
US

IV. Provider business mailing address

7320 SW HUNZIKER RD STE 201
TIGARD OR
97223-2301
US

V. Phone/Fax

Practice location:
  • Phone: 503-778-0787
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: