Healthcare Provider Details

I. General information

NPI: 1467922856
Provider Name (Legal Business Name): MICHAEL DAVID JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2018
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 E LINCOLN RD
WOODBURN OR
97071-5137
US

IV. Provider business mailing address

2045 SILVERTON RD NE
SALEM OR
97301-0100
US

V. Phone/Fax

Practice location:
  • Phone: 503-982-9300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number201401353RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number201401353RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: