Healthcare Provider Details

I. General information

NPI: 1639246291
Provider Name (Legal Business Name): MARY JO WOOD LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2507 MAIN AVE N STE B
TILLAMOOK OR
97141-9297
US

IV. Provider business mailing address

2507 MAIN AVE N STE B
TILLAMOOK OR
97141-9297
US

V. Phone/Fax

Practice location:
  • Phone: 503-842-1201
  • Fax: 503-842-0001
Mailing address:
  • Phone: 503-842-1201
  • Fax: 503-842-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC1313
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: