=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144585332
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA J HANSEN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2012
-----------------------------------------------------
Last Update Date | 08/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1614 SE STEPHENS ST
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97470-4000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-375-0314
-----------------------------------------------------
Fax | 541-440-3554
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 721
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97470-0151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-375-0314
-----------------------------------------------------
Fax | 541-896-4120
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | C2891
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------