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General NPI Number Information
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NPI Number | 1083419733
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Entity Type | Organization
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Legal Business Name | THE EASTSIDE CLINIC LLC
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Dates
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Enumeration Date | 02/17/2025
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Last Update Date | 02/17/2025
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Provider Practice Location Address
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Address Line | 1409 NE HANCOCK ST APT 8
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City | PORTLAND
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State | OR
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Zip | 97212-4480
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Country | US
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Telephone | 503-484-5068
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Fax |
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Provider Business Mailing Address
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Address Line | 1409 NE HANCOCK ST APT 8
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City | PORTLAND
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State | OR
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Zip | 97212-4480
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Country | US
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Telephone | 503-484-5068
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JEREMY WHISTON
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Credential |
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Telephone | 503-484-5068
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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