=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699077966
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER KATHLEEN CONNOR-SMITH PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2010
-----------------------------------------------------
Last Update Date | 11/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5331 SW MACADAM AVE SUITE 363
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97239-6104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-338-3481
-----------------------------------------------------
Fax | 971-285-4510
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5331 SW MACADAM AVE SUITE 363
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97239-6104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-338-3481
-----------------------------------------------------
Fax | 971-285-4510
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TB0200X
-----------------------------------------------------
Taxonomy Name | Cognitive & Behavioral Psychologist
-----------------------------------------------------
License Number | 1496
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 1496
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------