Provider Demographics
NPI:1043772411
Name:BIRD, JILL R (QMHA, PSS, PWS, THW)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:R
Last Name:BIRD
Suffix:
Gender:F
Credentials:QMHA, PSS, PWS, THW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 E LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071-5137
Mailing Address - Country:US
Mailing Address - Phone:503-982-9300
Mailing Address - Fax:503-982-9308
Practice Address - Street 1:1605 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-5137
Practice Address - Country:US
Practice Address - Phone:503-982-9300
Practice Address - Fax:503-982-9308
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW3372175T00000X
OR23-QMHA-R-3419101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW000003372OtherOREGON HEALTH AUTHORITY
OR23-QMHA-R-3419OtherMENTAL HEALTH AND ADDICTION CERTIFICATION BOARD OF OREGON