Jacob Christian Wickham, CMPSS
Individual provider Active NPI Addiction (Substance Use Disorder) Counselor · Campo, CA
NPI 1376306183 · NPPES record last updated Dec 17, 2025
Key facts
- NPI
- 1376306183
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Addiction (Substance Use Disorder) Counselor 101YA0400X
- License
- R1536221123 (CA)
- Practice address
- 1777 Buckman Springs Rd
Campo, CA 91906-2022 - Phone
- (619) 478-5696
- Fax
- (619) 478-2404
- NPI assigned
- Feb 5, 2024
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| R1536221123 | CA | MD | Addiction (Substance Use Disorder) Counselor |
| MPSS-ZWRITX | CA | MD | Peer Specialist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| San Diego Freedom Ranch, Inc. | Past |
Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Addiction (Substance Use Disorder) Counselor | 101YA0400X | R1536221123 | CA | Yes |
| Peer Specialist | 175T00000X | MPSS-ZWRITX | CA |
Addresses
Primary practice location
1777 Buckman Springs Rd
Campo, CA 91906-2022
Mailing address
1777 Buckman Springs Rd
Campo, CA 91906-2022
Phone (619) 478-5696
Other providers in Campo, CA
- John Vargas
- Vista Hill Foundation
- Michael Derek Waters
- Ora Jo Weldy
- Zachary White
- Billy Don Wilson
- Christopher Lee Wright
All providers in Campo, CA · Addiction (Substance Use Disorder) Counselor in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 17, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.