Healthcare Provider Details

I. General information

NPI: 1699659409
Provider Name (Legal Business Name): MIKEL ALEXANDER JACOBO QMHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 E 11TH AVE FL 2
EUGENE OR
97401-3746
US

IV. Provider business mailing address

1160 W 15TH AVE APT 207
EUGENE OR
97402-3910
US

V. Phone/Fax

Practice location:
  • Phone: 458-205-7085
  • Fax: 458-205-7089
Mailing address:
  • Phone: 909-319-2978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number25-QMHA-I-004910
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number25-QMHA-I-004910
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: