Healthcare Provider Details

I. General information

NPI: 1114695962
Provider Name (Legal Business Name): SOUTHERN OREGON PSYCHIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2021
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 E JACKSON ST
MEDFORD OR
97504-7029
US

IV. Provider business mailing address

1104 E JACKSON ST
MEDFORD OR
97504-7029
US

V. Phone/Fax

Practice location:
  • Phone: 541-313-3617
  • Fax: 769-235-0747
Mailing address:
  • Phone: 541-313-3617
  • Fax: 769-235-0747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RACHAEL GORDON
Title or Position: MEDICAL DIRECTOR/FOUNDER
Credential: PMHNP
Phone: 541-313-3617