Southern Oregon CBT LLC

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

Legal business name

SOUTHERN OREGON CBT LLC

Practice address

235 W Main St
Jacksonville, OR 97530-9278

Phone

(541) 204-4933

Fax

(800) 433-1396

NPI assigned

Aug 7, 2020

Last updated

Oct 29, 2024By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Kacy Mullen, PHDNPI 1801224795

Title

Owner

Phone

(541) 500-8655

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in OR

Enrollment records 1

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Kacy Mullen, PH.D.

  • Psychologist
  • White City, OR
  • NPI 1801224795
  Medicare reassignment Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1596758400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1730160000000",
    "number": "1306456058",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 4752",
            "city": "MEDFORD",
            "state": "OR",
            "postal_code": "975010197",
            "telephone_number": "541-500-8655"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "235 W MAIN ST",
            "city": "JACKSONVILLE",
            "state": "OR",
            "postal_code": "975309278",
            "telephone_number": "541-204-4933",
            "fax_number": "800-433-1396"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN OREGON CBT LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-08-07",
        "last_updated": "2024-10-29",
        "certification_date": "2024-10-29",
        "status": "A",
        "authorized_official_last_name": "MULLEN",
        "authorized_official_first_name": "KACY",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "541-500-8655",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Cory Ruth, MS, RDN
• Bear Anaya Satterstrom
• Jordan Schreiber, L.AC.
• Sisters of Providence in Oregon (PMG South Jacksonville)
• Mikinzie Smoot,, ND
• Nathan M Tanner, DMD
• Christina Thompson, M.A.
• Three Sisters Midwifery LLC
• Jessica Nicole Vail, LMT
• Valley Denture Care LLC

• Clinical Psychologist in Jacksonville, OR
• Providers in Jacksonville, OR by specialty
• Clinical Psychologist in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 29, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.