=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154593788
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RGJ ENTERPRISES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2008
-----------------------------------------------------
Last Update Date | 03/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15739 SW HAWK CT
-----------------------------------------------------
City | SHERWOOD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97140-8676
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-625-7307
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15739 SW HAWK COURT
-----------------------------------------------------
City | SHERWOOD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97140-8676
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-625-7307
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | MS. ROBYN JUOLA
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 503-625-7307
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | L2322
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------