Provider Demographics
NPI:1194869149
Name:SIMON-THOMAS, JENNIFER ANNE (PHD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANNE
Last Name:SIMON-THOMAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5319 SW WESTGATE DR STE 168
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2430
Mailing Address - Country:US
Mailing Address - Phone:503-707-0348
Mailing Address - Fax:971-266-2868
Practice Address - Street 1:4850 SW SCHOLLS FERRY RD STE 301
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-1696
Practice Address - Country:US
Practice Address - Phone:503-707-0348
Practice Address - Fax:971-266-2868
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT355103TC0700X
OR2570103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT52511OtherBCBS
MT0493017Medicaid