Provider Demographics
NPI:1962566323
Name:CHESHIRE, JENNIFER L (CDP,CADCIII)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:CHESHIRE
Suffix:
Gender:F
Credentials:CDP,CADCIII
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 1:15520 NE 82ND CIR
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-3745
Practice Address - Country:US
Practice Address - Phone:360-608-6887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00004411101YA0400X
OR05-11-93101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
OR0000WDBCHMedicare ID - Type UnspecifiedGROUP NUMBER