Healthcare Provider Details

I. General information

NPI: 1104284900
Provider Name (Legal Business Name): BRIDGET JENKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2016
Last Update Date: 01/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HILYARD ST STE 570
EUGENE OR
97401-8168
US

IV. Provider business mailing address

687 CHESHIRE AVE
EUGENE OR
97402-5060
US

V. Phone/Fax

Practice location:
  • Phone: 458-205-7070
  • Fax: 458-205-7089
Mailing address:
  • Phone: 541-684-4168
  • Fax: 541-684-4156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16-05-21
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500719317
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: