Provider Demographics
NPI:1184084519
Name:INDIGO, JENNIFER (AS, QMHA)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:INDIGO
Suffix:
Gender:F
Credentials:AS, QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 IDYLWOOD DR SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-3903
Mailing Address - Country:US
Mailing Address - Phone:971-900-6898
Mailing Address - Fax:
Practice Address - Street 1:182 SW ACADEMY ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1996
Practice Address - Country:US
Practice Address - Phone:503-623-9289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-26
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X, 171M00000X
OR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty