Healthcare Provider Details

I. General information

NPI: 1508015975
Provider Name (Legal Business Name): JACOB DICKINSON M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2008
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9670 SW BEAVERTON HILLSDALE HWY
BEAVERTON OR
97005-3307
US

IV. Provider business mailing address

10824 SE OAK ST STE 314
MILWAUKIE OR
97222-6694
US

V. Phone/Fax

Practice location:
  • Phone: 971-229-4009
  • Fax: 866-324-6009
Mailing address:
  • Phone: 971-229-4009
  • Fax: 866-324-6009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC2887
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0845
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: