Jack R Agen, MA

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

C1077 Issued in OR

Practice address

880 82ND Dr
Gladstone, OR 97027-1803

Phone

(503) 659-5515

Fax

(503) 659-1994

NPI assigned

Dec 20, 2006

Last updated

Jul 9, 2007By the provider in NPPES

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Specialty

Mental Health Counselor

Education

Other, 1993

Medicare assignment

May accept Medicare assignment

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Master of Arts

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: lifestancehealth.jackagen@148835.advancedmd-direct.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Western Psychological and Counseling Services LLC

  dba LifeStance Health

  • Clinical Psychologist
  • Tacoma, WA
  • NPI 1912008178

  Professional

  NPD
• Western Psychological and Counseling Services LLC

  dba LifeStance Health

  • Clinical Psychologist
  • Vancouver, WA
  • NPI 1629345731
  NPD (past)

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

{
    "created_epoch": "1166572800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183939200000",
    "number": "1902960362",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 82819",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972820819",
            "telephone_number": "503-233-5405",
            "fax_number": "503-233-2696"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "880 82ND DR",
            "city": "GLADSTONE",
            "state": "OR",
            "postal_code": "970271803",
            "telephone_number": "503-659-5515",
            "fax_number": "503-659-1994"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "AGEN",
        "first_name": "JACK",
        "middle_name": "R",
        "credential": "MA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-12-20",
        "last_updated": "2007-07-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "OR",
            "license": "C1077",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "164936",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Rachel E Adams
• Advokate Speech Therapy LLC
• Jonathan Hubert Aebischer, FNP
• Aegis Group Practice LLC
• Aegis Group Practice LLC
• Natalie Elizabeth Arakelian
• Julia A. Arambul
• Shelley Atkeson
• Aura Integrative Health LLC
• Brenda Backhaus, RN

• Professional Counselor in Gladstone, OR
• Providers in Gladstone, OR by specialty
• Professional Counselor in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.