Provider Demographics
NPI:1386340438
Name:JARRELL, LAMAYA T (PSS/QMHA-R)
Entity type:Individual
Prefix:
First Name:LAMAYA
Middle Name:T
Last Name:JARRELL
Suffix:
Gender:F
Credentials:PSS/QMHA-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:1310 SW 17TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-2522
Practice Address - Country:US
Practice Address - Phone:503-231-2641
Practice Address - Fax:503-467-4077
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHA-R-3567101YM0800X
ORTHW000106422175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500815209Medicaid