Provider Demographics
NPI:1679284582
Name:MAHON, JILLIAN LISA MARIE (CADC-R, CRM)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:LISA MARIE
Last Name:MAHON
Suffix:
Gender:F
Credentials:CADC-R, CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7118
Mailing Address - Country:US
Mailing Address - Phone:541-200-1530
Mailing Address - Fax:541-772-0284
Practice Address - Street 1:534 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7118
Practice Address - Country:US
Practice Address - Phone:541-200-1530
Practice Address - Fax:541-772-0284
Is Sole Proprietor?:No
Enumeration Date:2022-12-12
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW000104724OtherTRADITIONAL HEALTH WORKER, PEER SUPPORT SPECIALIST