Provider Demographics
NPI:1043033236
Name:GRACE, JON (PSS-YS, QMHA-R)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:GRACE
Suffix:
Gender:M
Credentials:PSS-YS, QMHA-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1710
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-0516
Mailing Address - Country:US
Mailing Address - Phone:541-516-4099
Mailing Address - Fax:
Practice Address - Street 1:1059 NW MADRAS HWY
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1416
Practice Address - Country:US
Practice Address - Phone:541-323-5330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-05
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000106413175T00000X
OR22-QMHA-R-2796101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist