Provider Demographics
NPI:1447022413
Name:MATHIS, JESSICA CRYSTAL (QMHA-R)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:CRYSTAL
Last Name:MATHIS
Suffix:
Gender:F
Credentials:QMHA-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 NE 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3960
Mailing Address - Country:US
Mailing Address - Phone:971-396-2971
Mailing Address - Fax:
Practice Address - Street 1:1817 NE 6TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3960
Practice Address - Country:US
Practice Address - Phone:971-396-2971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHA-R-4429101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health