MEDICARE: DR. CONSTANCE JANENE JACKSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	MD18409	OR

General Provider Information

NPI Number	:	1083703391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CONSTANCE JANENE JACKSON MD

Provider Business Mailing Address
First Line	:	3439 NE SANDY BLVD
Second Line	:	PMB 375
City	:	PORTLAND
State	:	OR
Zip	:	97232-1959
Country	:	US
Telephone Number	:	503-284-8841
Fax Number	:	503-282-3302

Provider Business Practice Location Address
First Line	:	4800 SW MACADAM AVE
Second Line	:	SUITE 350
City	:	PORTLAND
State	:	OR
Zip	:	97239-3925
Country	:	US
Telephone Number	:	503-297-6656
Fax Number	:	503-297-5779

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	11/04/2011

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