Provider Demographics
NPI:1013289578
Name:ARCHIBALD, JEREMY JOHN (MH INTERN)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:JOHN
Last Name:ARCHIBALD
Suffix:
Gender:M
Credentials:MH INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3867 WOLVERINE ST NE BLDG F
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-4266
Mailing Address - Country:US
Mailing Address - Phone:503-588-5352
Mailing Address - Fax:
Practice Address - Street 1:3867 WOLVERINE ST NE BLDG F
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-4266
Practice Address - Country:US
Practice Address - Phone:503-588-5352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-31
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health