Provider Demographics
NPI:1710023395
Name:LANE, JONATHAN MATHEW (PSS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MATHEW
Last Name:LANE
Suffix:
Gender:M
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 SW HOOKER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-4747
Mailing Address - Country:US
Mailing Address - Phone:503-922-9174
Mailing Address - Fax:
Practice Address - Street 1:1258 HIGH ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3238
Practice Address - Country:US
Practice Address - Phone:541-342-8437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OR175T00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor