Basic Information
| Provider Information | |||||||||
| NPI: | 1497821680 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JASPER MOUNTAIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 37875 JASPER LOWELL RD | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974389751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417471235 | ||||||||
| FaxNumber: | 5417474722 | ||||||||
| Practice Location | |||||||||
| Address1: | 37875 JASPER LOWELL RD | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974389751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417471235 | ||||||||
| FaxNumber: | 5417474722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 09/07/2009 | ||||||||
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| AuthorizedOfficialLastName: | LANDAUER | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5417471235 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | OR | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 385HR2055X | OR | N | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child | 320800000X | OR | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 313495 | 05 | OR | MEDICAID | 178087 | 05 | OR | MEDICAID |