Healthcare Provider Details

I. General information

NPI: 1801522420
Provider Name (Legal Business Name): JUSTIN JACOBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10151 SE SUNNYSIDE RD STE 480
CLACKAMAS OR
97015-5705
US

IV. Provider business mailing address

10151 SE SUNNYSIDE RD STE 480
CLACKAMAS OR
97015-5705
US

V. Phone/Fax

Practice location:
  • Phone: 971-915-0046
  • Fax:
Mailing address:
  • Phone: 971-915-0046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberR272
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4321
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: