Provider Demographics
NPI:1629746557
Name:WYNANT, JESSICA L (LPC)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:L
Last Name:WYNANT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:PALMINI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:1915 NE STUCKI AVE STE 308
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97006-6951
Mailing Address - Country:US
Mailing Address - Phone:503-476-1013
Mailing Address - Fax:971-209-7262
Practice Address - Street 1:1915 NE STUCKI AVE STE 308
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97006-6951
Practice Address - Country:US
Practice Address - Phone:503-813-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC8592101Y00000X
ORR7785101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500807379Medicaid