Provider Demographics
NPI:1184461360
Name:FLICK, JAX ROMAN
Entity type:Individual
Prefix:
First Name:JAX
Middle Name:ROMAN
Last Name:FLICK
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 1:1450 N PRESCOTT ST APT 320
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3206
Mailing Address - Country:US
Mailing Address - Phone:801-854-8865
Mailing Address - Fax:
Practice Address - Street 1:1827 NE 44TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1443
Practice Address - Country:US
Practice Address - Phone:503-963-6494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-13
Last Update Date:2024-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORABA-IN-10245553106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician