NPIMap

Organization Active NPI

Mindful Therapy Pacific NW, LLC

  • Mental Health Counselor
  • Portland, OR
National Provider Identifier
1437810538
Registry record updated Sep 30, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Health CounselorTaxonomy code 101YM0800X
Legal business name
MINDFUL THERAPY PACIFIC NW, LLC
Practice address
2245 SW Troy St
Portland, OR 97219-2657
Phone
(503) 341-6393
Fax
(888) 920-2077
NPI assigned
Jan 1, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 30, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jennifer Samsom, LPC, LMHCNPI 1003129115
Title
Executive Director
Phone
(503) 341-6393

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health CounselorGroup: 193400000X SINGLE SPECIALTY GROUP 101YM0800X Primary

Addresses

Primary practice location

2245 SW Troy St
Portland, OR 97219-2657

Mailing address

2245 SW Troy St
Portland, OR 97219-2657
Phone (503) 341-6393

Other identifiers 2

IdentifierTypeStateIssuer
1003129115MedicaidOR
500827243MedicaidOR

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240502004127 OR Part B Supplier - Clinic/Group Practice 4486094745 Receives reassigned benefits from 1 practitioner
Practice locations: Portland, OR

National Provider Directory

National Provider Directory

Locations

4055 SW Garden Home Rd
Portland, OR 97219
Phone (503) 766-4000

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1640995200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1727654400000",
    "number": "1437810538",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2245 SW TROY ST",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972192657",
            "telephone_number": "503-341-6393",
            "fax_number": "888-920-2077"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2245 SW TROY ST",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972192657",
            "telephone_number": "503-341-6393",
            "fax_number": "888-920-2077"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MINDFUL THERAPY PACIFIC NW, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-01-01",
        "last_updated": "2024-09-30",
        "certification_date": "2024-09-30",
        "status": "A",
        "authorized_official_last_name": "SAMSOM",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "503-341-6393",
        "authorized_official_credential": "LPC, LMHC"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1003129115",
            "state": "OR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500827243",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Portland, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 30, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.