=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982281291
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARAH JEAN TEDRICK LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2021
-----------------------------------------------------
Last Update Date | 11/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 NE ROBERTS AVE STE 200
-----------------------------------------------------
City | GRESHAM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97030-7484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-300-6073
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13424 SE 169TH AVE # A120
-----------------------------------------------------
City | HAPPY VALLEY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97015-8744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-960-2817
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | C5821
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------