Provider Demographics
NPI:1427457928
Name:WALDROFF, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WALDROFF
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 1:565 UNION ST NE STE 100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2416
Mailing Address - Country:US
Mailing Address - Phone:503-949-6668
Mailing Address - Fax:
Practice Address - Street 1:565 UNION ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2477
Practice Address - Country:US
Practice Address - Phone:503-949-6668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1427457928Medicaid