Provider Demographics
NPI:1497821680
Name:JASPER MOUNTAIN
Entity Type:Organization
Organization Name:JASPER MOUNTAIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CARITA
Authorized Official - Middle Name:CHANTEL
Authorized Official - Last Name:LIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-747-1235
Mailing Address - Street 1:37875 JASPER LOWELL RD
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:OR
Mailing Address - Zip Code:97438-9751
Mailing Address - Country:US
Mailing Address - Phone:541-747-1235
Mailing Address - Fax:541-747-4722
Practice Address - Street 1:37875 JASPER LOWELL RD
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:OR
Practice Address - Zip Code:97438-9751
Practice Address - Country:US
Practice Address - Phone:541-747-1235
Practice Address - Fax:541-747-4722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR320800000X, 322D00000X, 385HR2055X
323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR313495Medicaid
OR178087Medicaid