MEDICARE: ROBERT JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist		OR

General Provider Information

NPI Number	:	1538864038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT JACKSON

Provider Business Mailing Address
First Line	:	PO BOX 320
Second Line	:
City	:	SILETZ
State	:	OR
Zip	:	97380-0320
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 PORTLAND ST
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97405-3153
Country	:	US
Telephone Number	:	541-515-6321
Fax Number	:	541-515-6195

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2023
Last Update Date	:	10/05/2023

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Directions to “ ROBERT JACKSON ” Practice Location

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