Provider Demographics
NPI:1710707575
Name:WHISTON, JEREMY (MA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:WHISTON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 NE HANCOCK ST APT 8
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4480
Mailing Address - Country:US
Mailing Address - Phone:971-255-3272
Mailing Address - Fax:
Practice Address - Street 1:333 SW TAYLOR ST STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-2446
Practice Address - Country:US
Practice Address - Phone:503-484-5068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR9845101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health