Provider Demographics
NPI:1972484996
Name:LARYEA, JESSICA (RBAI)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LARYEA
Suffix:
Gender:F
Credentials:RBAI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7133 N LOMBARD ST STE 104
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-3205
Mailing Address - Country:US
Mailing Address - Phone:971-420-7372
Mailing Address - Fax:503-850-7602
Practice Address - Street 1:7133 N LOMBARD ST STE 104
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-3205
Practice Address - Country:US
Practice Address - Phone:971-420-7372
Practice Address - Fax:503-850-7602
Is Sole Proprietor?:No
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORABA-IN-10258491106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician