Healthcare Provider Details

I. General information

NPI: 1508525924
Provider Name (Legal Business Name): JESSICA J BLADT CRM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2021
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

389 SW SCALEHOUSE CT STE 130
BEND OR
97702-3241
US

IV. Provider business mailing address

389 SW SCALEHOUSE CT STE 130
BEND OR
97702-3241
US

V. Phone/Fax

Practice location:
  • Phone: 541-306-4446
  • Fax: 541-550-2011
Mailing address:
  • Phone: 541-306-4446
  • Fax: 541-550-2011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberTG-25-380
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number24-03-11071
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number21-CRM-778
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: