Healthcare Provider Details

I. General information

NPI: 1821953589
Provider Name (Legal Business Name): ALI NICOLE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 WEMBLEY PARK RD
LAKE OSWEGO OR
97034-2632
US

IV. Provider business mailing address

2800 WEMBLEY PARK RD
LAKE OSWEGO OR
97034-2632
US

V. Phone/Fax

Practice location:
  • Phone: 503-745-6568
  • Fax: 503-734-6568
Mailing address:
  • Phone: 503-745-6568
  • Fax: 503-734-6568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number200340761RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: