Provider Demographics
NPI:1558790071
Name:GILGAN, JEROME THOMAS (CADC I)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:THOMAS
Last Name:GILGAN
Suffix:
Gender:M
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2318 NE MLK BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3715
Mailing Address - Country:US
Mailing Address - Phone:503-802-0298
Mailing Address - Fax:503-335-8636
Practice Address - Street 1:2318 NE MLK BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3715
Practice Address - Country:US
Practice Address - Phone:503-802-0298
Practice Address - Fax:503-335-8636
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR08-06-23101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)