Basic Information
| Provider Information | |||||||||
| NPI: | 1104284900 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | BRIDGET | ||||||||
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| Mailing Information | |||||||||
| Address1: | 687 CHESHIRE AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974025060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416844168 | ||||||||
| FaxNumber: | 5416844156 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 HILYARD ST STE 570 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974018168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4582057070 | ||||||||
| FaxNumber: | 4582057089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2016 | ||||||||
| LastUpdateDate: | 01/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 16-05-21 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 175T00000X | OR | Y |
ID Information
| ID | Type | State | Issuer | Description | 500719317 | 05 | OR | MEDICAID |