Provider Demographics
NPI:1730558669
Name:DODARO, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DODARO
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 1:172 NE HAYES ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-2356
Mailing Address - Country:US
Mailing Address - Phone:503-353-9415
Mailing Address - Fax:
Practice Address - Street 1:17882 SE MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-6103
Practice Address - Country:US
Practice Address - Phone:503-353-9415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372600000X
OR12-09-09101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR292910Medicaid