Healthcare Provider Details

I. General information

NPI: 1497821680
Provider Name (Legal Business Name): JASPER MOUNTAIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37875 JASPER LOWELL RD
JASPER OR
97438-9751
US

IV. Provider business mailing address

37875 JASPER LOWELL RD
JASPER OR
97438-9751
US

V. Phone/Fax

Practice location:
  • Phone: 541-747-1235
  • Fax: 541-747-4722
Mailing address:
  • Phone: 541-747-1235
  • Fax: 541-747-4722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number StateOR

VIII. Authorized Official

Name: CARITA CHANTEL LIVELY
Title or Position: COMPLIANCE SPECIALIST
Credential:
Phone: 541-747-1235