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:M
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 1:1640 HISLOP DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-5318
Mailing Address - Country:US
Mailing Address - Phone:208-404-1501
Mailing Address - Fax:
Practice Address - Street 1:7309 BALMER ST
Practice Address - Street 2:
Practice Address - City:HILL AFB
Practice Address - State:UT
Practice Address - Zip Code:84056-5012
Practice Address - Country:US
Practice Address - Phone:801-777-7909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW61327515101YA0400X
101YA0400X
UT13486284-3501101YM0800X, 1041C0700X
ORA5574101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health