Healthcare Provider Details

I. General information

NPI: 1336707843
Provider Name (Legal Business Name): IGNITE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

438 CHARNELTON ST STE 102
EUGENE OR
97401-2760
US

IV. Provider business mailing address

1175 LODGEPOLE CT
SPRINGFIELD OR
97477-7635
US

V. Phone/Fax

Practice location:
  • Phone: 541-870-2904
  • Fax:
Mailing address:
  • Phone: 541-870-2904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: JASMINE ROSE PENTER
Title or Position: OWNER/CLINICIAN
Credential: MSW, LCSW
Phone: 541-870-2904