Provider Demographics
NPI:1902130511
Name:SKILES, JACK CHARLES
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:CHARLES
Last Name:SKILES
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 1:182 SW ACADEMY ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1922
Mailing Address - Country:US
Mailing Address - Phone:503-831-5971
Mailing Address - Fax:503-831-1726
Practice Address - Street 1:182 S.W. ACADEMY ST.
Practice Address - Street 2:304 ACADEMY BUILDING
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1922
Practice Address - Country:US
Practice Address - Phone:503-831-5971
Practice Address - Fax:503-831-1726
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)