Individual
DEFORREST KWESI JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CADC-1
Contact information
Practice address
12670 NW BARNES RD STE 200, PORTLAND, OR 97229-9001
(971) 232-3850
Mailing address
11400 SE 90TH AVE APT 1424, HAPPY VALLEY, OR 97086-2626
(503) 432-7975
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
T-20-047
OR
Other
Enumeration date
02/03/2020
Last updated
03/03/2022
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