Individual
JACKIE LUCKETT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1500 NE IRVING ST, PORTLAND, OR 97232-2243
(503) 258-4222
Mailing address
629 NW AUTUMNCREEK WAY APT I201, ALOHA, OR 97006-8753
(503) 515-4826
Taxonomy
Speciality
Code
Description
License number
State
172V00000X
Community Health Worker
Primary
172V00000X
OR
Other
Enumeration date
03/06/2008
Last updated
03/06/2008
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