Healthcare Provider Details

I. General information

NPI: 1043772411
Provider Name (Legal Business Name): JILL R BIRD QMHA, PSS, PWS, THW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 E LINCOLN RD
WOODBURN OR
97071-5137
US

IV. Provider business mailing address

1605 E LINCOLN RD
WOODBURN OR
97071-5137
US

V. Phone/Fax

Practice location:
  • Phone: 503-982-9300
  • Fax: 503-982-9308
Mailing address:
  • Phone: 503-982-9300
  • Fax: 503-982-9308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number23-QMHA-R-3419
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberTHW3372
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: