Provider Demographics
NPI:1992379671
Name:MILLER, JACOB ROBERT (CADC I)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ROBERT
Last Name:MILLER
Suffix:
Gender:M
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 NW 9TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-6169
Mailing Address - Country:US
Mailing Address - Phone:541-768-6769
Mailing Address - Fax:541-768-9771
Practice Address - Street 1:777 NW 9TH ST STE 102
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-6169
Practice Address - Country:US
Practice Address - Phone:541-768-6769
Practice Address - Fax:541-768-9771
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15-02-08101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)