Provider Demographics
NPI:1912445941
Name:ERICKS, JEFFREY LEE (RN)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:LEE
Last Name:ERICKS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2681 EDGEMONT ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-8824
Mailing Address - Country:US
Mailing Address - Phone:541-967-0197
Mailing Address - Fax:
Practice Address - Street 1:2681 EDGEMONT ST SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-8824
Practice Address - Country:US
Practice Address - Phone:541-967-0197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-09
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20014909RN163WP0808X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health