Provider Demographics
NPI:1942706106
Name:BASS, SHANE JACKSON
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:JACKSON
Last Name:BASS
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 1:16026 NE SANDY BLVD APT 130
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-8810
Mailing Address - Country:US
Mailing Address - Phone:360-449-9685
Mailing Address - Fax:
Practice Address - Street 1:12901 SE 97TH AVE STE 180
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-7903
Practice Address - Country:US
Practice Address - Phone:971-206-6337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
OR103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst