Healthcare Provider Details

I. General information

NPI: 1285886051
Provider Name (Legal Business Name): JON R JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 08/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

337 FOWLER ST
ROSEBURG OR
97470
US

IV. Provider business mailing address

272 MEDICAL LOOP SUITE E
ROSEBURG OR
97471
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-3532
  • Fax: 541-440-3554
Mailing address:
  • Phone: 541-440-3532
  • Fax: 541-440-3554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: