Provider Demographics
NPI:1043362163
Name:JENKS, LYN MCNEILL (MA)
Entity type:Individual
Prefix:
First Name:LYN
Middle Name:MCNEILL
Last Name:JENKS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:LYN
Other - Middle Name:MCNEILL
Other - Last Name:NEWBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:2235 RIVER HEIGHTS CIRCLE
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068
Mailing Address - Country:US
Mailing Address - Phone:503-248-2189
Mailing Address - Fax:503-248-2189
Practice Address - Street 1:818 NW 17TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209
Practice Address - Country:US
Practice Address - Phone:503-248-2189
Practice Address - Fax:503-248-2189
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5047103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
111406Medicare ID - Type Unspecified