Provider Demographics
NPI:1265099550
Name:UTTERBACK, JARED
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:UTTERBACK
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 1:61181 LODGEPOLE DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2880
Mailing Address - Country:US
Mailing Address - Phone:458-202-9632
Mailing Address - Fax:
Practice Address - Street 1:695 SW MILL VIEW WAY STE 207
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1557
Practice Address - Country:US
Practice Address - Phone:458-202-9632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR5529106H00000X
ORT1907106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500767552Medicaid