Provider Demographics
NPI:1730218850
Name:RITZKE RUTHERFORD, JEAN (QMHA)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:RITZKE RUTHERFORD
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 4TH ST APT 205
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-2437
Mailing Address - Country:US
Mailing Address - Phone:503-842-8201
Mailing Address - Fax:503-815-1870
Practice Address - Street 1:906 MAIN AVE
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3816
Practice Address - Country:US
Practice Address - Phone:503-842-8201
Practice Address - Fax:503-815-1870
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR197749Medicaid
OROOOOWCGKJMedicare ID - Type UnspecifiedMENTAL HEALTH