Basic Information
| Provider Information | |||||||||
| NPI: | 1962540344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | M.ED., CADC1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2548 PHIPPS CIR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973051949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035663768 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3325 HAROLD DR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973051339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033632021 | ||||||||
| FaxNumber: | 5033634820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YA0400X | 061131 | OR | X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 061131 | 01 | OR | CADC1 CERTIFICATION | OTHER | 4835505 | 01 | OR | DRIVER'S LICENSE | OTHER |