Healthcare Provider Details

I. General information

NPI: 1508279787
Provider Name (Legal Business Name): JASON VANCE GERMANY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 06/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 SW WASHINGTON ST
PORTLAND OR
97205-2327
US

IV. Provider business mailing address

PO BOX 3007
PORTLAND OR
97208-3007
US

V. Phone/Fax

Practice location:
  • Phone: 503-535-1192
  • Fax:
Mailing address:
  • Phone: 360-931-0391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000000000
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: