Healthcare Provider Details

I. General information

NPI: 1043464597
Provider Name (Legal Business Name): JACK BLANTON WILLS M.S., P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 KINCAID ST
EUGENE OR
97401-3737
US

IV. Provider business mailing address

1414 KINCAID ST
EUGENE OR
97401-3737
US

V. Phone/Fax

Practice location:
  • Phone: 541-505-2080
  • Fax:
Mailing address:
  • Phone: 541-505-2080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5052
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: