Provider Demographics
NPI:1962067470
Name:STONEBRAKER, JEAN MICHELLE (QMHA-I)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:MICHELLE
Last Name:STONEBRAKER
Suffix:
Gender:F
Credentials:QMHA-I
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:STONEBRAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:QMHA-I
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:2019-05-09
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19-QMHA-I-02189101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500763103Medicaid