Provider Demographics
NPI:1902463086
Name:COBURN, JESSE WAYNE (LSCW, CADC II, SUDP)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:WAYNE
Last Name:COBURN
Suffix:
Gender:
Credentials:LSCW, CADC II, SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 E CRONQUIST RD
Mailing Address - Street 2:
Mailing Address - City:ALLYN
Mailing Address - State:WA
Mailing Address - Zip Code:98524-8745
Mailing Address - Country:US
Mailing Address - Phone:208-404-1501
Mailing Address - Fax:
Practice Address - Street 1:5257 NE MLK JR BLVD STE 201
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3283
Practice Address - Country:US
Practice Address - Phone:503-954-2077
Practice Address - Fax:503-954-2089
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP61374175101YA0400X
OR19-10-32101YA0400X
WALW613275151041C0700X
ORL108301041C0700X
UT13486284-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)