Basic Information
| Provider Information | |||||||||
| NPI: | 1710023395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANE | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | MATHEW | ||||||||
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| Credential: | PSS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 SW HOOKER ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972014747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039229174 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1258 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974013238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413428437 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 06/21/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 175T00000X | OR | Y | 101Y00000X | OR | N | Behavioral Health & Social Service Providers | Counselor |
No ID Information.