MEDICARE: NICOLE JORDAN JONES QMHA

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	103K00000X	Behavior Analyst
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1881093466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE JORDAN JONES QMHA

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

Provider Business Practice Location Address
First Line	:	421 SW 5TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97204-2205
Country	:	US
Telephone Number	:	503-238-0769
Fax Number	:

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

Provider Enumeration Date	:	08/19/2014
Last Update Date	:	12/07/2021

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