Healthcare Provider Details

I. General information

NPI: 1750253902
Provider Name (Legal Business Name): JONATHAN ROBERTS-STARK QMHA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ALICIA ROBERTS-STARK QMHA

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 E 12TH AVE
EUGENE OR
97401-3208
US

IV. Provider business mailing address

261 E 12TH AVE
EUGENE OR
97401-3208
US

V. Phone/Fax

Practice location:
  • Phone: 541-342-8437
  • Fax:
Mailing address:
  • Phone: 541-342-8437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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