Provider Demographics
NPI:1720534746
Name:FAUBLE, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:FAUBLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 S HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-3113
Mailing Address - Country:US
Mailing Address - Phone:541-774-8201
Mailing Address - Fax:541-774-7979
Practice Address - Street 1:140 S HOLLY ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3113
Practice Address - Country:US
Practice Address - Phone:541-774-8201
Practice Address - Fax:541-774-7979
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR104100000X1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical