Active NPI
Jesse C Staubach
- Peer Specialist
- Coos Bay, OR
National Provider Identifier
1114560802
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Peer Specialist
- License
- THW000003807
- Practice address
- 320 Central Ave Ste 304
Coos Bay, OR 97420-2241 - Phone
- (541) 366-7640
- NPI assigned
- Oct 24, 2019
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Peer Specialist | 175T00000X | THW000003807 | OR | Primary |
Addresses
Primary practice location
320 Central Ave Ste 304
Coos Bay, OR 97420-2241
Mailing address
PO Box 802
Coos Bay, OR 97420-0148
Phone (541) 295-9240
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| THW000003807 | OR | MD | Peer Specialist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1571875200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1571875200000",
"number": "1114560802",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 802",
"city": "COOS BAY",
"state": "OR",
"postal_code": "974200148",
"telephone_number": "541-295-9240"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "320 CENTRAL AVE STE 304",
"city": "COOS BAY",
"state": "OR",
"postal_code": "974202241",
"telephone_number": "541-366-7640"
}
],
"practiceLocations": [],
"basic": {
"last_name": "STAUBACH",
"first_name": "JESSE",
"middle_name": "C",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2019-10-24",
"last_updated": "2019-10-24",
"status": "A"
},
"taxonomies": [
{
"code": "175T00000X",
"taxonomy_group": "",
"desc": "Peer Specialist",
"state": "OR",
"license": "THW000003807",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Coos Bay, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 24, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.