Provider Demographics
NPI:1144592148
Name:MERRILL, JANE MARY (LPC)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:MARY
Last Name:MERRILL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3528 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97138-5049
Mailing Address - Country:US
Mailing Address - Phone:419-322-4450
Mailing Address - Fax:
Practice Address - Street 1:850 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138-6824
Practice Address - Country:US
Practice Address - Phone:419-322-4450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-06
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012878101YP2500X
ORC3782101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional