Healthcare Provider Details

I. General information

NPI: 1477911477
Provider Name (Legal Business Name): JESSE N SPAIN CADC II/QMHA-I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 NE 2ND ST
GRESHAM OR
97030-7514
US

IV. Provider business mailing address

12104 SE TIBBETTS ST
PORTLAND OR
97266-1049
US

V. Phone/Fax

Practice location:
  • Phone: 971-274-3757
  • Fax: 503-912-5740
Mailing address:
  • Phone: 971-212-5312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15-01-09
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number19-QMHA-I-00297
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17-04-13
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier500700056
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier500722603
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: