Provider Demographics
NPI:1679043939
Name:MASON, JAMES AUSTIN
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:AUSTIN
Last Name:MASON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 NE MANZANITA AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1400
Mailing Address - Country:US
Mailing Address - Phone:541-787-4075
Mailing Address - Fax:
Practice Address - Street 1:109 NE MANZANITA AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1400
Practice Address - Country:US
Practice Address - Phone:541-479-8847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18-10-18101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1871703702Medicaid