Healthcare Provider Details

I. General information

NPI: 1548567688
Provider Name (Legal Business Name): JONATHAN ROY SMITH CADC II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2011
Last Update Date: 02/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 W 12TH AVE
EUGENE OR
97401-6215
US

IV. Provider business mailing address

149 W. 12TH AVE.
EUGENE OR
97401-3008
US

V. Phone/Fax

Practice location:
  • Phone: 541-344-0031
  • Fax: 541-344-0772
Mailing address:
  • Phone: 541-344-0031
  • Fax: 541-344-0772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number930569684
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number930569684
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: