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General NPI Number Information
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NPI Number | 1609273168
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Entity Type | Individual
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Provider Name | JACKSON WILSHIRE M.A., LPC-INT
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Gender | Male
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Dates
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Enumeration Date | 11/28/2014
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Last Update Date | 07/30/2025
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Provider Practice Location Address
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Address Line | 1230 7TH AVE
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City | LONGVIEW
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State | WA
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Zip | 98632-3166
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Country | US
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Telephone | 800-813-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 500 NE MULTNOMAH ST STE 100
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City | PORTLAND
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State | OR
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Zip | 97232-2031
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Country | US
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Telephone | 800-813-2000
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Fax | 855-524-5255
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LH60925398
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License Number State | WA
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