Individual
JACLYN GRACE EVANS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1122 NE 122ND AVE, PORTLAND, OR 97230-2081
(855) 237-9882
Mailing address
1122 NE 122ND AVE STE A102, PORTLAND, OR 97230-2082
(855) 337-9882
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
T-19-378
CADC
OR
Enumeration date
07/24/2019
Last updated
07/24/2019
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