Provider Demographics
NPI:1164843470
Name:PADILLA, JESSICA (CADCII QMHAII PSS CH)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PADILLA
Suffix:
Gender:F
Credentials:CADCII QMHAII PSS CH
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:REANNE
Other - Last Name:BONACKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:QMHA, PSS, CHW, BS
Mailing Address - Street 1:PO BOX 1700
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0414
Mailing Address - Country:US
Mailing Address - Phone:541-229-7038
Mailing Address - Fax:541-464-4474
Practice Address - Street 1:3031 NE STEPHENS ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-6237
Practice Address - Country:US
Practice Address - Phone:458-803-4057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-04
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000002914175T00000X, 172V00000X
OR22-QMHA-II-000058101YM0800X
OR22-II-20220101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health