Healthcare Provider Details

I. General information

NPI: 1306484126
Provider Name (Legal Business Name): JESSIE AISHA KALEIKAU MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2019
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19365 SW 65TH AVE STE 105
TUALATIN OR
97062-9196
US

IV. Provider business mailing address

19365 SW 65TH AVE STE 105
TUALATIN OR
97062-9196
US

V. Phone/Fax

Practice location:
  • Phone: 971-208-5765
  • Fax: 971-979-1079
Mailing address:
  • Phone: 971-208-5765
  • Fax: 971-979-1079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number85-1546935
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: