Provider Demographics
NPI:1164996278
Name:VIDA, JACOB THOMAS
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:THOMAS
Last Name:VIDA
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 1:250 CHURCH ST SE STE 202
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3921
Mailing Address - Country:US
Mailing Address - Phone:503-385-8395
Mailing Address - Fax:
Practice Address - Street 1:3321 HAROLD DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1339
Practice Address - Country:US
Practice Address - Phone:503-399-5597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)