Provider Demographics
NPI:1871015941
Name:SLOAN II, JEROME M (LCSW/CADC III//QMHP)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:M
Last Name:SLOAN II
Suffix:
Gender:M
Credentials:LCSW/CADC III//QMHP
Other - Prefix:
Other - First Name:JEROME
Other - Middle Name:M
Other - Last Name:MASSAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADC III/CSWA/QMHP
Mailing Address - Street 1:5606 N WILLIAMS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2455
Mailing Address - Country:US
Mailing Address - Phone:541-212-7089
Mailing Address - Fax:
Practice Address - Street 1:1110 SE ALDER ST.
Practice Address - Street 2:SUITE 301 PMB #51
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214
Practice Address - Country:US
Practice Address - Phone:541-212-7089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-11
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL10965104100000X
OR21-06-30017101YA0400X, 101YA0400X
OR19-07-37101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500765279Medicaid
OR500765754Medicaid