Provider Demographics
NPI:1063743847
Name:MENDRO, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MENDRO
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 1:3739 NE SENATE ST.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1312 SW WASHINGTON
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97208
Practice Address - Country:US
Practice Address - Phone:503-984-3331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)