MEDICARE: MS. JEAN LOUISE WATERMAN LCSW

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	1272	OR

General Provider Information

NPI Number	:	1942484407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JEAN LOUISE WATERMAN LCSW

Provider Business Mailing Address
First Line	:	7805 SW TAYLORS FERRY RD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97223-9072
Country	:	US
Telephone Number	:	503-244-3509
Fax Number	:

Provider Business Practice Location Address
First Line	:	605 SE 39TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-3216
Country	:	US
Telephone Number	:	503-231-7480
Fax Number	:	503-731-9574

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

Provider Enumeration Date	:	12/19/2007
Last Update Date	:	12/19/2007

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