Healthcare Provider Details

I. General information

NPI: 1366363194
Provider Name (Legal Business Name): JESHE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2026
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20370 POE SHOLES DR
BEND OR
97703-7938
US

IV. Provider business mailing address

393 CENTER RIDGE DR
CULVER OR
97734-1501
US

V. Phone/Fax

Practice location:
  • Phone: 541-306-4628
  • Fax:
Mailing address:
  • Phone: 831-566-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: