Healthcare Provider Details

I. General information

NPI: 1114880481
Provider Name (Legal Business Name): JESSE ROBERTSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W MAIN ST
MEDFORD OR
97501-2756
US

IV. Provider business mailing address

300 W MAIN ST
MEDFORD OR
97501-2756
US

V. Phone/Fax

Practice location:
  • Phone: 541-772-1777
  • Fax:
Mailing address:
  • Phone: 541-772-1777
  • Fax: 541-724-2410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25-CRM-5042
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: