Healthcare Provider Details

I. General information

NPI: 1407604374
Provider Name (Legal Business Name): JARED ROBERT PETTIT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JARED SNYDER

II. Dates (important events)

Enumeration Date: 05/07/2024
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 NW 6TH AVE
ESTACADA OR
97023-7713
US

IV. Provider business mailing address

18600 SE MCLOUGHLIN BLVD
MILWAUKIE OR
97267-6723
US

V. Phone/Fax

Practice location:
  • Phone: 503-395-0435
  • Fax:
Mailing address:
  • Phone: 503-946-3267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDPT.CO.70090940
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number26-08-12016
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: