Basic Information
| Provider Information | |||||||||
| NPI: | 1902130511 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SKILES | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 182 SW ACADEMY ST | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | DALLAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973381922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038315971 | ||||||||
| FaxNumber: | 5038311726 | ||||||||
| Practice Location | |||||||||
| Address1: | 182 S.W. ACADEMY ST. | ||||||||
| Address2: | 304 ACADEMY BUILDING | ||||||||
| City: | DALLAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973381922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038315971 | ||||||||
| FaxNumber: | 5038311726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2009 | ||||||||
| LastUpdateDate: | 09/29/2009 | ||||||||
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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 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.