Provider Demographics
NPI:1902960362
Name:AGEN, JACK R (MA)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:R
Last Name:AGEN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82819
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97282-0819
Mailing Address - Country:US
Mailing Address - Phone:503-233-5405
Mailing Address - Fax:503-233-2696
Practice Address - Street 1:880 82ND DR
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-1803
Practice Address - Country:US
Practice Address - Phone:503-659-5515
Practice Address - Fax:503-659-1994
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1077101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
OR0000WDBCHMedicare ID - Type UnspecifiedGROUP NUMBER