Individual
JACK R AGEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MA
Contact information
Practice address
880 82ND DR, GLADSTONE, OR 97027-1803
(503) 659-5515
(503) 659-1994
Mailing address
PO BOX 82819, PORTLAND, OR 97282-0819
(503) 233-5405
(503) 233-2696
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
C1077
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
164936
—
OR
Enumeration date
12/20/2006
Last updated
07/09/2007
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