=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619523248
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENNIFER MCKAGUE, LPC, LCC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2019
-----------------------------------------------------
Last Update Date | 08/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2775 SW 17TH PL STE 7
-----------------------------------------------------
City | REDMOND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97756-1254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-788-0795
-----------------------------------------------------
Fax | 541-610-1707
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2775 SW 17TH PL STE 7
-----------------------------------------------------
City | REDMOND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97756-1254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-788-0795
-----------------------------------------------------
Fax | 541-610-1707
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | JENNIFER CATHERINE MCKAAGUE
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 541-788-0795
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------