=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386369783
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY ANN JANKE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2022
-----------------------------------------------------
Last Update Date | 10/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 65 SW YAMHILL ST STE 300
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97204-3316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-878-8885
-----------------------------------------------------
Fax | 971-297-1360
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 65 SW YAMHILL ST STE 300
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97204-3316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-523-0296
-----------------------------------------------------
Fax | 503-523-0296
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SC61557302
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | A15306
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------