Provider Demographics
NPI:1316308588
Name:FORD, JESSICA
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:
Last Name:FORD
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 1:58147 COLUMBIA RIVER HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-6226
Mailing Address - Country:US
Mailing Address - Phone:503-396-5322
Mailing Address - Fax:
Practice Address - Street 1:58147 COLUMBIA RIVER HWY
Practice Address - Street 2:SUITE C
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-6226
Practice Address - Country:US
Practice Address - Phone:503-396-5322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500698719Medicaid