Provider Demographics
NPI:1043464597
Name:WILLS, JACK BLANTON (MS, PA)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:BLANTON
Last Name:WILLS
Suffix:
Gender:M
Credentials:MS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 KINCAID ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3737
Mailing Address - Country:US
Mailing Address - Phone:541-505-2080
Mailing Address - Fax:
Practice Address - Street 1:1414 KINCAID ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3737
Practice Address - Country:US
Practice Address - Phone:541-505-2080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5052103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical