Healthcare Provider Details

I. General information

NPI: 1437278736
Provider Name (Legal Business Name): JACOB E SKOKAN CADC I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 SE 12TH AVENUE
PORTLAND OR
97214-1342
US

IV. Provider business mailing address

232 NW 6TH AVENUE
PORTLAND OR
97209-3609
US

V. Phone/Fax

Practice location:
  • Phone: 503-546-9975
  • Fax: 503-546-9976
Mailing address:
  • Phone: 503-200-3923
  • Fax: 503-241-7419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number08-08-39
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: