Healthcare Provider Details

I. General information

NPI: 1265633085
Provider Name (Legal Business Name): JASON DUANE ANDERSON QMHA-R
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date: 02/07/2008
Reactivation Date: 03/13/2008

III. Provider practice location address

1058 NE 12TH ST
BEND OR
97701-4412
US

IV. Provider business mailing address

1058 NE 12TH ST
BEND OR
97701-4412
US

V. Phone/Fax

Practice location:
  • Phone: 541-678-5320
  • Fax: 541-678-5412
Mailing address:
  • Phone: 541-678-5320
  • Fax: 541-678-5412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: