Healthcare Provider Details

I. General information

NPI: 1699890764
Provider Name (Legal Business Name): MS. NANCY MAY DEJESUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 03/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2145 CENTENNIAL PLZ
EUGENE OR
97401-2421
US

IV. Provider business mailing address

3255 GATEWAY ST 139
SPRINGFIELD OR
97401-2421
US

V. Phone/Fax

Practice location:
  • Phone: 541-684-5825
  • Fax: 541-684-6826
Mailing address:
  • Phone: 503-887-5213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number99-11-09
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: