Basic Information
| Provider Information | |||||||||
| NPI: | 1174758700 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARNOLD | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | O'RYAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, MHP, LICSWA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ARNOLD | ||||||||
| OtherFirstName: | JASON | ||||||||
| OtherMiddleName: | O'RYAN ARNOLD | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW, MHP, LICSWA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1845 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986681845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603978484 | ||||||||
| FaxNumber: | 3603978494 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 E FOURTH PLAIN BLVD | ||||||||
| Address2: | BUILDING 17 SUITE B222 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986613713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603978484 | ||||||||
| FaxNumber: | 3603978494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2009 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CG0585448 | WA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | SC61115841 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 08098 | 01 | OK | ODMHSAS | OTHER |