Healthcare Provider Details

I. General information

NPI: 1710280367
Provider Name (Legal Business Name): JILL CAROL SCOTT CADC 1
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2010
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 5TH ST
BROOKINGS OR
97415-9199
US

IV. Provider business mailing address

621 W MADRONE ST
ROSEBURG OR
97470-3090
US

V. Phone/Fax

Practice location:
  • Phone: 541-813-2535
  • Fax: 541-813-2536
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: