Provider Demographics
NPI:1477911477
Name:SPAIN, JESSE N (CADC II/QMHA-I)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:N
Last Name:SPAIN
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 1:12104 SE TIBBETTS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-1049
Mailing Address - Country:US
Mailing Address - Phone:971-212-5312
Mailing Address - Fax:
Practice Address - Street 1:620 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7514
Practice Address - Country:US
Practice Address - Phone:971-274-3757
Practice Address - Fax:503-912-5740
Is Sole Proprietor?:No
Enumeration Date:2016-02-04
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15-01-09101YA0400X
OR19-QMHA-I-00297101YM0800X
OR101YM0800X
OR17-04-13101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500700056Medicaid
OR500722603Medicaid