Healthcare Provider Details

I. General information

NPI: 1245803097
Provider Name (Legal Business Name): ASHLEY MARIE JACOBE QMHA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19003 SE 12TH WAY
VANCOUVER WA
98683-9784
US

IV. Provider business mailing address

4900 MEADOWS RD STE 250
LAKE OSWEGO OR
97035-3173
US

V. Phone/Fax

Practice location:
  • Phone: 360-607-6579
  • Fax:
Mailing address:
  • Phone: 360-607-6579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: