Provider Demographics
NPI:1417310236
Name:JUMPING EAGLE, ADRIANNA (CADC II)
Entity Type:Individual
Prefix:
First Name:ADRIANNA
Middle Name:
Last Name:JUMPING EAGLE
Suffix:
Gender:F
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 E MAIN ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7448
Mailing Address - Country:US
Mailing Address - Phone:541-779-1282
Mailing Address - Fax:541-779-2081
Practice Address - Street 1:1003 E MAIN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7448
Practice Address - Country:US
Practice Address - Phone:541-779-1282
Practice Address - Fax:541-779-2081
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14-R-45101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134150Medicaid