Healthcare Provider Details

I. General information

NPI: 1750571345
Provider Name (Legal Business Name): JEFFERSON BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 NE E ST
GRANTS PASS OR
97526-2326
US

IV. Provider business mailing address

550 NE E ST
GRANTS PASS OR
97526-2326
US

V. Phone/Fax

Practice location:
  • Phone: 541-955-9565
  • Fax: 541-955-8290
Mailing address:
  • Phone: 541-955-9565
  • Fax: 541-955-8290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number119488
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. BOB NIKKEL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 541-955-9565