Provider Demographics
NPI:1669411377
Name:COLUMBIA RIVER MENTAL HEALTH SERVICES
Entity type:Organization
Organization Name:COLUMBIA RIVER MENTAL HEALTH SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-993-3000
Mailing Address - Street 1:PO BOX 1337
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98666-1337
Mailing Address - Country:US
Mailing Address - Phone:360-993-3000
Mailing Address - Fax:360-993-3047
Practice Address - Street 1:6926 NE FOURTH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661
Practice Address - Country:US
Practice Address - Phone:360-993-3000
Practice Address - Fax:360-993-3047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA138251S00000X
WA06 0894 00261QM2800X, 261QR0405X
WA067261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1992775Medicaid
WA7117195Medicaid
WA06288OtherREGENCE BCBS
WA1980705Medicaid
WA7035975Medicaid
WA9630716Medicaid
WA9234600Medicaid
WA7035975Medicaid