Healthcare Provider Details

I. General information

NPI: 1114190808
Provider Name (Legal Business Name): JUDE WALSH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S MAIN ST STE 104
LEBANON OR
97355-3335
US

IV. Provider business mailing address

550 S MAIN ST STE 104
LEBANON OR
97355-3335
US

V. Phone/Fax

Practice location:
  • Phone: 541-722-5002
  • Fax:
Mailing address:
  • Phone: 541-722-5002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberL7544
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: