Provider Demographics
NPI:1780363689
Name:WILDER, JASMINE RIVER
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:RIVER
Last Name:WILDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 NE ROSELAWN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-3828
Mailing Address - Country:US
Mailing Address - Phone:505-795-1654
Mailing Address - Fax:
Practice Address - Street 1:12150 SW WESTFALL RD
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-7207
Practice Address - Country:US
Practice Address - Phone:503-610-3202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health