Provider Demographics
NPI:1629131305
Name:SMITH, JASON (PMHNP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3995 MARCOLA RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-7948
Mailing Address - Country:US
Mailing Address - Phone:541-726-1465
Mailing Address - Fax:541-726-5085
Practice Address - Street 1:3995 MARCOLA RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-7948
Practice Address - Country:US
Practice Address - Phone:541-726-1465
Practice Address - Fax:541-726-5085
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201606339NP-PP363LP0808X, 363LP0808X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical