Healthcare Provider Details

I. General information

NPI: 1003430802
Provider Name (Legal Business Name): JASON PRINZ BLUME
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2020
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 NW CHARBONNEAU ST. SUITE 201
BEND OR
97701
US

IV. Provider business mailing address

750 NW CHARBONNEAU ST SUITE 201
BEND OR
97701
US

V. Phone/Fax

Practice location:
  • Phone: 541-591-5669
  • Fax:
Mailing address:
  • Phone: 541-591-5669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-89480
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: