=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093022345
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAY VANDENBOGAARD M.S., NCC, CADC III
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2010
-----------------------------------------------------
Last Update Date | 09/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2225 PACIFIC BOULEVARD SE SUITE 207
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-704-0762
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2225 PACIFIC BOULEVARD SE SUITE 207
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-704-0762
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | R1427
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 07-12-61
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | R1427
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | R1427
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------