Provider Demographics
NPI:1063719417
Name:MCALLISTER, JEREMY (MA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:MCALLISTER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:JEREMY
Other - Middle Name:
Other - Last Name:MCALLISTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:4838 NE SANDY BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2091
Mailing Address - Country:US
Mailing Address - Phone:503-284-6754
Mailing Address - Fax:503-284-6754
Practice Address - Street 1:4838 NE SANDY BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2091
Practice Address - Country:US
Practice Address - Phone:503-284-6754
Practice Address - Fax:503-284-6754
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3882101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
13612353OtherCAQH