Provider Demographics
NPI:1063241982
Name:EICHLIN, JENNIFER DAWN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:EICHLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33630 OPHIR RD
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-8510
Mailing Address - Country:US
Mailing Address - Phone:416-987-1445
Mailing Address - Fax:
Practice Address - Street 1:615 5TH ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9199
Practice Address - Country:US
Practice Address - Phone:541-708-9581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-30
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24-QMHP-R-3019101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health