Healthcare Provider Details

I. General information

NPI: 1174051569
Provider Name (Legal Business Name): JESSICA MARIE BETTENDORF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSIA BETTENDORF

II. Dates (important events)

Enumeration Date: 05/30/2017
Last Update Date: 01/30/2026
Certification Date: 01/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7507 NE 51ST ST
VANCOUVER WA
98662-6007
US

IV. Provider business mailing address

7507 NE 51ST ST
VANCOUVER WA
98662-6007
US

V. Phone/Fax

Practice location:
  • Phone: 360-906-1190
  • Fax:
Mailing address:
  • Phone: 360-906-1190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number61456725
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR8594
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH61588961
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC11140
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: