| Southern Oregon Cbt Llc | |
|
235 W Main St Jacksonville OR 97530-9278 | |
| (541) 204-4933 | |
| (800) 433-1396 |
| Full Name | Southern Oregon Cbt Llc |
|---|---|
| Speciality | Psychologist |
| Location | 235 W Main St, Jacksonville, Oregon |
| Authorized Official Name and Position | Kacy Mullen (OWNER) |
| Authorized Official Contact | 5415008655 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Southern Oregon Cbt Llc Po Box 4752 Medford OR 97501-0197 Ph: (541) 500-8655 | Southern Oregon Cbt Llc 235 W Main St Jacksonville OR 97530-9278 Ph: (541) 204-4933 |
| NPI Number | 1306456058 |
|---|---|
| Provider Enumeration Date | 08/07/2020 |
| Last Update Date | 10/29/2024 |
| Certification Date | 10/29/2024 |
| Medicare PECOS PAC ID | 1355769050 |
|---|---|
| Medicare Enrollment ID | O20200911002305 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1306456058 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | (* (Not Available)) | Primary |
| Provider Name | Kacy Lynn Mullen |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1801224795 PECOS PAC ID: 1355567660 Enrollment ID: I20140723000295 |
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