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General NPI Number Information
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NPI Number | 1477847077
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Entity Type | Individual
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Provider Name | JONATHAN TAYLOR SHIELDS QMHA
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Gender | Male
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Dates
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Enumeration Date | 06/01/2011
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Last Update Date | 02/23/2015
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Provider Practice Location Address
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Address Line | 847 NE 19TH AVE
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City | PORTLAND
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State | OR
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Zip | 97232-2684
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Country | US
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Telephone | 971-282-5901
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Fax |
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Provider Business Mailing Address
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Address Line | 5402 NE HOYT ST
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City | PORTLAND
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State | OR
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Zip | 97213-3067
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Country | US
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Telephone | 971-282-5901
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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 | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 101Y00000X
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 372600000X
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Taxonomy Name | Adult Companion
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License Number |
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License Number State |
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