Individual
JUDY JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
745 NE 122ND AVE, PORTLAND, OR 97230-2001
(503) 252-0241
Mailing address
745 NE 122ND AVE, PORTLAND, OR 97230-2001
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
201408689LPN
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000
NONE OBTAINED
OR
Enumeration date
01/02/2023
Last updated
01/02/2023
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