Basic Information
| Provider Information | |||||||||
| NPI: | 1295237899 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | JASPER | ||||||||
| MiddleName: | DAMIEN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1189 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973391189 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3509 NW SAMARITAN DR STE 215 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973303893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417685235 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2018 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LMSW-37446 | ID | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | L12739 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.