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General NPI Number Information
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NPI Number | 1316246937
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Entity Type | Individual
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Provider Name | JACK RANDELL WELLS PSYD
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Gender | Male
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Dates
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Enumeration Date | 03/22/2011
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Last Update Date | 05/13/2025
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Provider Practice Location Address
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Address Line | 9135 SW BARNES RD STE 561
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City | PORTLAND
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State | OR
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Zip | 97225-6643
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Country | US
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Telephone | 503-216-2339
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3158
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City | PORTLAND
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State | OR
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Zip | 97208-3158
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Country | US
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Telephone | 503-215-6494
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 3238
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY.0005193
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License Number State | CO
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