Provider Demographics
NPI:1235531476
Name:JETT, BRANDON (CADC-II, QMHA-I)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:JETT
Suffix:
Gender:M
Credentials:CADC-II, QMHA-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16756
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0576
Mailing Address - Country:US
Mailing Address - Phone:503-654-2749
Mailing Address - Fax:503-208-2596
Practice Address - Street 1:537 SE ALDER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2231
Practice Address - Country:US
Practice Address - Phone:503-841-3157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR16-04-22101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health