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General NPI Number Information
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NPI Number | 1720667702
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Entity Type | Individual
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Provider Name | JEREMY RANDOLPH NAISH CADC-II, QMHA-II
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Gender | Male
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Dates
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Enumeration Date | 04/06/2021
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Last Update Date | 04/21/2025
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Provider Practice Location Address
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Address Line | 1712 NE SANDY BLVD
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City | PORTLAND
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State | OR
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Zip | 97232-2851
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Country | US
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Telephone | 503-496-6839
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Fax |
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Provider Business Mailing Address
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Address Line | 1712 NE SANDY BLVD
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City | PORTLAND
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State | OR
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Zip | 97232-2851
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Country | US
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Telephone | 971-712-9258
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 23-05-20277
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 23-QMHA-I-003747
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License Number State | OR
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