Healthcare Provider Details

I. General information

NPI: 1538200043
Provider Name (Legal Business Name): JEFFREY LOUIS HICKS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 07/08/2007
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:
Title or Position:
Credential:
Phone: