MEDICARE: JENNIFER WILCOX

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C23285	OTHER		CRC

General Provider Information

NPI Number	:	1396891289
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER WILCOX

Provider Business Mailing Address
First Line	:	PO BOX 8459
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97207-8459
Country	:	US
Telephone Number	:	503-238-0769
Fax Number	:

Provider Business Practice Location Address
First Line	:	4212 SE DIVISION ST
Second Line	:	SUITE 100
City	:	PORTLAND
State	:	OR
Zip	:	97206-1628
Country	:	US
Telephone Number	:	503-238-0705
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	06/03/2014

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Directions to “ JENNIFER WILCOX ” Practice Location

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