Provider Demographics
NPI:1932695731
Name:WILBURN, JASON LEE SR (CADC 1, CRM)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:LEE
Last Name:WILBURN
Suffix:SR
Gender:M
Credentials:CADC 1, CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3793 RIVER RD N
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-4827
Mailing Address - Country:US
Mailing Address - Phone:503-304-7002
Mailing Address - Fax:503-304-7049
Practice Address - Street 1:3793 RIVER RD N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4827
Practice Address - Country:US
Practice Address - Phone:503-304-7002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR180532101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)