Provider Demographics
NPI:1417473992
Name:JAIMES, LICCI (PSYD)
Entity Type:Individual
Prefix:
First Name:LICCI
Middle Name:
Last Name:JAIMES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6149
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97007-0149
Mailing Address - Country:US
Mailing Address - Phone:503-352-8657
Mailing Address - Fax:503-352-8658
Practice Address - Street 1:115 NE MAY LN
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-9272
Practice Address - Country:US
Practice Address - Phone:503-472-1338
Practice Address - Fax:503-434-8597
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3095103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical