Provider Demographics
NPI:1063759231
Name:COOPER, JENNIFER (LPC, CADCII)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:LPC, CADCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604A NE 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-4244
Mailing Address - Country:US
Mailing Address - Phone:503-915-8290
Mailing Address - Fax:
Practice Address - Street 1:3500 NE MLK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2093
Practice Address - Country:US
Practice Address - Phone:503-237-8205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10R21101YA0400X
ORC3479101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)