Healthcare Provider Details

I. General information

NPI: 1164843470
Provider Name (Legal Business Name): JESSICA PADILLA CADCII QMHAII PSS CH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA REANNE BONACKER QMHA, PSS, CHW, BS

II. Dates (important events)

Enumeration Date: 01/04/2014
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 NE STEPHENS ST
ROSEBURG OR
97470-6237
US

IV. Provider business mailing address

PO BOX 1700
ROSEBURG OR
97470-0414
US

V. Phone/Fax

Practice location:
  • Phone: 458-803-4057
  • Fax:
Mailing address:
  • Phone: 541-229-7038
  • Fax: 541-464-4474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22-II-20220
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number22-QMHA-II-000058
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberTHW000002914
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberTHW000002914
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: