Healthcare Provider Details

I. General information

NPI: 1467100859
Provider Name (Legal Business Name): JOEL EBEN DUPUIS PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 LIBERTY ST SE
SALEM OR
97302-4347
US

IV. Provider business mailing address

1655 LIBERTY ST SE
SALEM OR
97302-4347
US

V. Phone/Fax

Practice location:
  • Phone: 541-556-6743
  • Fax: 530-339-7557
Mailing address:
  • Phone: 541-556-6743
  • Fax: 530-339-7557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number201141589RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10023447
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: