Individual
NICOLE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
8355 N INTERSTATE AVE, PORTLAND, OR 97217-6716
(503) 568-1408
Mailing address
7931 NE HALSEY ST STE 307, PORTLAND, OR 97213-6793
(208) 899-2604
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
T-25-5762
OR
175T00000X
Peer Specialist
Primary
105324
OR
251S00000X
Community/Behavioral Health Agency
25-QMHA-R-6774
OR
Other
Enumeration date
08/21/2025
Last updated
10/03/2025
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