Healthcare Provider Details

I. General information

NPI: 1316608441
Provider Name (Legal Business Name): MOTIVATIONAL PARENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 CARMEL CT
ROSEBURG OR
97471-4606
US

IV. Provider business mailing address

1414 NW VALLEY VIEW DR # 107
ROSEBURG OR
97471-1760
US

V. Phone/Fax

Practice location:
  • Phone: 541-900-8244
  • Fax:
Mailing address:
  • Phone: 541-900-8244
  • Fax: 541-524-4200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JASON WILCOX
Title or Position: DIRECTOR
Credential: LCSW
Phone: 541-900-8244