Healthcare Provider Details

I. General information

NPI: 1083434807
Provider Name (Legal Business Name): NICOLE ANNE DICKASON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 E HERSEY ST
ASHLAND OR
97520-2361
US

IV. Provider business mailing address

1215 SW G ST
GRANTS PASS OR
97526-2544
US

V. Phone/Fax

Practice location:
  • Phone: 541-476-2373
  • Fax:
Mailing address:
  • Phone: 541-476-2373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: