Healthcare Provider Details

I. General information

NPI: 1407821937
Provider Name (Legal Business Name): JEFFREY L. HICKS, PH.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 W 19TH AVE
EUGENE OR
97401-3822
US

IV. Provider business mailing address

41 W 19TH AVE
EUGENE OR
97401-3822
US

V. Phone/Fax

Practice location:
  • Phone: 541-683-5024
  • Fax:
Mailing address:
  • Phone: 541-683-5024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number436
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. JEFFREY L. HICKS
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 541-683-5024