Basic Information
| Provider Information | |||||||||
| NPI: | 1619343027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEAD | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | M | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | HEAD | ||||||||
| OtherFirstName: | JASON | ||||||||
| OtherMiddleName: | MILTON | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CADC1,CRM | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 900 MAIN ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970451869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 5032082596 | ||||||||
| Practice Location | |||||||||
| Address1: | 2602 ARBOR DR | ||||||||
| Address2: | |||||||||
| City: | WEST LINN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970681104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033873884 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2015 | ||||||||
| LastUpdateDate: | 12/05/2019 | ||||||||
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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 | 15-5-14 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 175T00000X | 17-CRM-032 | OR | Y |
No ID Information.