Provider Demographics
NPI:1871941500
Name:DEPRIEST, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DEPRIEST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3871 FAIRVIEW INDUSTRIAL DR SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-1180
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1160 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4143
Practice Address - Country:US
Practice Address - Phone:503-391-9762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2019-08-28
Deactivation Date:2018-03-17
Deactivation Code:
Reactivation Date:2018-05-09
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)