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General NPI Number Information
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NPI Number | 1417810946
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Entity Type | Organization
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Legal Business Name | JESSICA RAE PSYCHOTHERAPY LLC
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Dates
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Enumeration Date | 12/03/2025
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Last Update Date | 12/03/2025
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Provider Practice Location Address
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Address Line | 1011 SW EMKAY DR STE 101
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City | BEND
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State | OR
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Zip | 97702-3162
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Country | US
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Telephone | 541-890-3061
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Fax |
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Provider Business Mailing Address
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Address Line | 19903 PORCUPINE DR
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City | BEND
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State | OR
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Zip | 97702-3986
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICAL SOCIAL WORKER
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Name | JESSICA RAE
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Credential | LCSW
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Telephone | 541-890-3061
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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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