Individual
JACK WHITE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRM , THW
Contact information
Practice address
1741 NEWMARK AVE, COOS BAY, OR 97420-4704
(541) 851-7151
Mailing address
155 S EMPIRE BLVD, COOS BAY, OR 97420-3374
(541) 851-7151
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
22-CRM-1099
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
THW000107022
THW
OR
Enumeration date
09/13/2022
Last updated
09/13/2022
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