Basic Information
| Provider Information | |||||||||
| NPI: | 1558790071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILGAN | ||||||||
| FirstName: | JEROME | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | CADC I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2318 NE MLK BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972123715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038020298 | ||||||||
| FaxNumber: | 5033358636 | ||||||||
| Practice Location | |||||||||
| Address1: | 2318 NE MLK BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972123715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038020298 | ||||||||
| FaxNumber: | 5033358636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2013 | ||||||||
| LastUpdateDate: | 03/23/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 08-06-23 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.