Provider Demographics
NPI:1174237523
Name:REID, JACOB RAYMOND (CSWA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RAYMOND
Last Name:REID
Suffix:
Gender:M
Credentials:CSWA
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 320
Mailing Address - Street 2:
Mailing Address - City:SILETZ
Mailing Address - State:OR
Mailing Address - Zip Code:97380-0320
Mailing Address - Country:US
Mailing Address - Phone:541-270-1909
Mailing Address - Fax:
Practice Address - Street 1:200 GWEE SHUT RD
Practice Address - Street 2:
Practice Address - City:SILETZ
Practice Address - State:OR
Practice Address - Zip Code:97380-2036
Practice Address - Country:US
Practice Address - Phone:541-270-1909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health