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General NPI Number Information
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NPI Number | 1902463086
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Entity Type | Individual
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Provider Name | JESSE WAYNE COBURN LSCW, CADC II, SUDP
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Gender | Male
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Dates
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Enumeration Date | 05/23/2019
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Last Update Date | 06/12/2025
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Provider Practice Location Address
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Address Line | 5257 NE MLK JR BLVD STE 201
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City | PORTLAND
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State | OR
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Zip | 97211-3283
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Country | US
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Telephone | 503-954-2077
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Fax | 503-954-2089
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Provider Business Mailing Address
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Address Line | 371 E CRONQUIST RD
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City | ALLYN
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State | WA
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Zip | 98524-8745
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Country | US
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Telephone | 208-404-1501
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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 | CP61374175
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 19-10-32
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | L10830
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License Number State | OR
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LW61327515
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License Number State | WA
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