Provider Demographics
NPI:1629010996
Name:HICKERSON, JESS W (MD)
Entity Type:Individual
Prefix:DR
First Name:JESS
Middle Name:W
Last Name:HICKERSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:400 NW WALNUT BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3874
Mailing Address - Country:US
Mailing Address - Phone:541-768-4680
Mailing Address - Fax:541-768-4681
Practice Address - Street 1:400 NW WALNUT BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3874
Practice Address - Country:US
Practice Address - Phone:541-768-4680
Practice Address - Fax:541-768-4681
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2013-03-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ORMD13896207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC91612Medicare UPIN