| Mindful Therapy Pacific Nw, Llc | |
|
2245 Sw Troy St Portland OR 97219-2657 | |
| (503) 341-6393 | |
| (888) 920-2077 |
| Full Name | Mindful Therapy Pacific Nw, Llc |
|---|---|
| Speciality | Counselor |
| Location | 2245 Sw Troy St, Portland, Oregon |
| Authorized Official Name and Position | Jennifer Samsom (EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 5033416393 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Mindful Therapy Pacific Nw, Llc 2245 Sw Troy St Portland OR 97219-2657 Ph: (503) 341-6393 | Mindful Therapy Pacific Nw, Llc 2245 Sw Troy St Portland OR 97219-2657 Ph: (503) 341-6393 |
| NPI Number | 1437810538 |
|---|---|
| Provider Enumeration Date | 01/01/2022 |
| Last Update Date | 09/30/2024 |
| Certification Date | 09/30/2024 |
| Medicare PECOS PAC ID | 4486094745 |
|---|---|
| Medicare Enrollment ID | O20240502004127 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1437810538 | NPI | - | NPPES |
| 1003129115 | Medicaid | OR | |
| 500827243 | Medicaid | OR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
| Provider Name | Jennifer D Samsom |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1003129115 PECOS PAC ID: 6204272305 Enrollment ID: I20240312001261 |
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