Provider Demographics
NPI:1366989832
Name:LANDER, JENNA N (LCSW)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:N
Last Name:LANDER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10201 SE MAIN ST STE 10
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2937
Mailing Address - Country:US
Mailing Address - Phone:503-255-2186
Mailing Address - Fax:
Practice Address - Street 1:10201 SE MAIN ST STE 10
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2937
Practice Address - Country:US
Practice Address - Phone:503-255-2186
Practice Address - Fax:503-255-2194
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL75021041C0700X
COSWP.0001182104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker