Healthcare Provider Details

I. General information

NPI: 1851828495
Provider Name (Legal Business Name): JACOB HICKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2017
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 NE HIGHWAY 99 STE B
VANCOUVER WA
98665-8890
US

IV. Provider business mailing address

7700 NE HIGHWAY 99 STE B
VANCOUVER WA
98665-8890
US

V. Phone/Fax

Practice location:
  • Phone: 360-699-8133
  • Fax:
Mailing address:
  • Phone: 360-699-8133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH60727731
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPH60727731
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: