Basic Information
| Provider Information | |||||||||
| NPI: | 1417310236 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUMPING EAGLE | ||||||||
| FirstName: | ADRIANNA | ||||||||
| MiddleName: | |||||||||
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| Credential: | CADC II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1003 E MAIN ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417791282 | ||||||||
| FaxNumber: | 5417792081 | ||||||||
| Practice Location | |||||||||
| Address1: | 1003 E MAIN ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417791282 | ||||||||
| FaxNumber: | 5417792081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2016 | ||||||||
| LastUpdateDate: | 03/30/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 14-R-45 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 134150 | 05 | OR | MEDICAID |