Provider Demographics
NPI:1629223243
Name:PROFESSIONAL THERAPEUTIC COMMUNITY NETWORK, INC
Entity Type:Organization
Organization Name:PROFESSIONAL THERAPEUTIC COMMUNITY NETWORK, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:503-391-7175
Mailing Address - Street 1:2905 RIVER RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-9754
Mailing Address - Country:US
Mailing Address - Phone:503-391-7175
Mailing Address - Fax:503-585-3303
Practice Address - Street 1:2905 RIVER RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-9754
Practice Address - Country:US
Practice Address - Phone:503-391-7175
Practice Address - Fax:503-585-3303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR251S00000X, 253J00000X, 320800000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No253J00000XAgenciesFoster Care Agency
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities