Provider Demographics
NPI:1558721340
Name:OCTARINE THERAPEUTIC MENTAL HEALTH SERVICES
Entity Type:Organization
Organization Name:OCTARINE THERAPEUTIC MENTAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:458-205-5725
Mailing Address - Street 1:492 E 13TH AVE
Mailing Address - Street 2:209
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:492 E 13TH AVE
Practice Address - Street 2:209
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4268
Practice Address - Country:US
Practice Address - Phone:458-205-5725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1508254517Medicaid