Provider Demographics
NPI:1730231960
Name:FISCHER, JACK RALPH (MSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:RALPH
Last Name:FISCHER
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 COMMERCIAL ST SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3462
Mailing Address - Country:US
Mailing Address - Phone:503-585-5764
Mailing Address - Fax:503-585-3638
Practice Address - Street 1:780 COMMERCIAL ST SE
Practice Address - Street 2:SUITE 100
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3462
Practice Address - Country:US
Practice Address - Phone:503-585-5764
Practice Address - Fax:503-585-3638
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1634101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1634OtherCLINICAL SOC. WK LICENSE
OR0000THLBQMedicare ID - Type UnspecifiedCLINICAL SOCIAL WORK