Individual
JENNIFER WALLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW, CADCIII
Contact information
Practice address
19500 SE STARK ST, PORTLAND, OR 97233-5757
(503) 278-0397
Mailing address
19500 SE STARK ST, PORTLAND, OR 97233-5757
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
12-03-77
OR
101YM0800X
Mental Health Counselor
—
—
1041C0700X
Clinical Social Worker
Primary
L5660
OR
Other
Enumeration date
09/26/2007
Last updated
12/28/2021
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