MEDICARE: JESSICA RAE PSYCHOTHERAPY LLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1417810946
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JESSICA RAE PSYCHOTHERAPY LLC

Provider Business Mailing Address
First Line	:	19903 PORCUPINE DR
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97702-3986
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1011 SW EMKAY DR STE 101
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97702-3162
Country	:	US
Telephone Number	:	541-890-3061
Fax Number	:

Authorized Official
Title or Position	:	LICENSED CLINICAL SOCIAL WORKER
Name	:	JESSICA RAE
Credential	:	LCSW
Telephone Number	:	541-890-3061

Provider Enumeration Date	:	12/03/2025
Last Update Date	:	12/03/2025

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