Provider Demographics
NPI:1073120994
Name:RICK, JEREMY ROBERT
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:ROBERT
Last Name:RICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9123 SE SAINT HELENS ST STE 175
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-6858
Mailing Address - Country:US
Mailing Address - Phone:503-509-5275
Mailing Address - Fax:
Practice Address - Street 1:9123 SE SAINT HELENS ST STE 175
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6858
Practice Address - Country:US
Practice Address - Phone:503-509-5275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC8024101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health